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Disabilty_Hutchinson `� „ APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR a DEDUCTION FROM ASSESSED VALUATION S` I. State Form 43710(R13/1-20) Prescribed by the Department of Local Government Finance 6‘260 \ Di'her Jl oa File Mark Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located. Filing Date: Form must be completed and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the property taxes are first due and payable. See reverse side for additional instructions and qualifications. Name of applicant\ (owner\ or contractc buyer) 1\\•-� SV lL"�-C�'\ rl-��^Y.^) Is applicant theael legal or equitable owner? It No,what is his/her exact share of interest? If owned with someone other than spouse, indicate with whom: es ❑ No If name on record is different than that of applicant,indicate below: Name of contract seller )(- Address of contract sell r(number and street,city,state,and ZIP code) Is the t rty in question. Real Property ❑ Annually Assessed Mobile Home(IC 6-1.1-7) Is applicant blind as defined in IC 12-7-2-21(11? Is applicant disabled and unable to engage in any substantial gainful activity as defined in IC 6-1.1-12-11(d)? ❑ Yes 12'No es ❑ No Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year exceed$17,0007 Yes ❑ No ❑ Yes L_ o Taxing district Key number/Legal description Record number(contract) Page number(contract) eSor�e_r-mil \tom al Q- -oa-1-l Q‘--k- c o. t 0 0 . 1[We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Address of applicant (number and street,city,state,and ZIP code) Address of authorized re resent-nr- (V 1i•er and street,city,state,all ZIP code) Signature o thorized representative P RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS Name of applicant Date filed(month,day year) r \- -\ \ 0_4N'I r�-`----o . Name of contractsler FILED IPt • Taxing district FEB 0 6 Z00_23 Key number/legal description TY AUDITOR r r) - , � - Off -`-�b� - C�C�C� . 3� ( - 0©3 Signature of unty Auditor Date signed GIBBON(month, COUN day,year) �v�s-.cam-� a .t�`h Q. A Ad.,. ti� 44Y z - -2 Social Security Administration Retirement, Survivors and Disability Insurance Notice of Award Mid-America Program Service Center 601 East Twelfth Street Kansas City, Missouri 64106-2817 Date: January 10, 2017