Disabilty_Wolf Al—. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
14,lL �����•...'`sss ' DEDUCTION FROM ASSESSED VALUATION
■!Y l
' `"i' State Form 43710(R13 I 1-20)
'6 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
Name erlolicant(owner or contract buyer
Is applic the sole legal or equitable o ner? ' If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
(Yes INo
If name on record is different than at f applicant,indicate below:
Name of contract sell , —1D
L
, .
E.
Address of contract selleAr@mbe�and slreet city,state,and ZIP code) s th property in question:
rr ff(( 11 110
22 Real Property ❑Annually Assessed
/ Mobile Home(IC 6-1.1-7)
Is applicant bl kFtWne22-,7r&:i 1 ? Is applicant disabled and unable to ngage in any substantial gainful activity
GIBSON COUNTY r as defined in IC 6-1.1-12-11(d)?
AUDITOR
[ Yes No Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cale ar y r
exceed$17,000?
Yes [ No ❑ Yes KNoTaxing district Key nu er Legal description Record number(contract) Page number(
0 2-.(- ),6- --1 7.-7-0 0 — 00 1 e 9--6_uzLI
, ,
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (numberta, street,city state,an ZIP code)
LA) R,1-1 I V r3v)
S�`� I _
Signature of authorized representati Address of authorized representative (number and street,city,statd,and ZIP code) `
Notice of Award
111'1161+1111111'1111111111h111111hIllilpilimillitilii •
0000338 00024560 2 MB 0.485 0602M3MCS6P1 T168 P15
BRIAN P WOLF
12447 ROSETTA DRIVE
- HAUBSTADT, IN 47639-7939
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