Disabilty_Sloan c I'
�E"44 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
4, 4a� DEDUCTION FROM ASSESSED VALUATION
i State Form 43710(R13/1-20) SOVI
3
Prescribed by the Department of Local Government Finance �rGwG'5to
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
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
Na of appli t(own r or contract buyer)
iRO1 Der .a' F-0,.ti 51 0a►'1
Is licant the sale I al or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
Lem res ❑ No
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the pr perty in question:
eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
[PCS [I] No Yes El 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$17,000?
es ❑ No es ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Fr-C--r 6 43-47-303 -bDO-aS(o.005 •
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
gfatfireitlL p4ij 1K;' Address of applicant (number and street,city,state,and ZIP code)
( Co E W o F vlc co �-.N two (
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date�filed(month,day,year) -
Name of contract seller
FEB 2 2 2073
Taxing district j
ffml (On mummy AUDIT A
Key number/legal description
%—1311 ^303' DCO_ eD-5 cQ - Oo5
Signature of County Auditor Date signed(month,day,year)
4o' t//c93,13
Social Security Administration
Retirement, Survivors and Disability Insurance
Notice of Award
Mid-America Program Service Center
601 East Twelfth Street
Kansas City, Missouri 64106-2859
Date: November 14, 2009
Claim Number: 303-60-4851HA
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