Disabilty_Mullen '
'VA^•r•� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
`i4.7,- < DEDUCTION FROM ASSESSED VALUATION
"' ,3i' State Form 43710(R13/1-20) (7005On QrS\t\ct' 1
'�FaTa/ Prescribed by the Department of Local Government Finance
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 contract buyer)
'-1—C11." rc-- P -€ne_Q o Re v\
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
D 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 property in question:
Zeal 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)?
E-res ❑ No E kes ❑ 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 IF/es ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
?r\,nceiron 06-la-07-/oa-co3 595- oag
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Sigh`iire`.i;df:`a,ppliearit,,--' ' Address of applicant (number and street,city,state,and ZIP code)
,fit rtic G l ,kr k,,J esk `- ?r\v ekovi N `t17670
Signature of authorized repre enlative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant f` /� Date fled(month,day,year)
-TO1 Y1l.11'.A rG— 4-'` .f._ //A�"/J�,'U k f
Name of contract seller FILED
Taxing district APR 0 5 Z023
rf t n G vi / __' /J
Key number/legal description i4,tzLC &
06 _ ID-
b't - (0 D_ 603 55
S ^ O D-g GIBSON COUNTY AUDITOR
Signature of County Auditor Date signed(month,day,year)
Avm
'• TAMMARA RENEE MULLEN
621 N WEST STREET
002823 PRINCETON IN 47670-1439
You are entitled to monthly disability benefits.
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