Disabilty_Hagan ).,.,•r APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
:.k..,.ry• #•' DEDUCTION FROM ASSESSED VALUATION -
'` Stale Form 43710(R13!1-20)
�'er 1 Prescribed by the Department of Local Government Finance IVl pc--:,„cafor ��
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
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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:
�es ❑ 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:
❑ Real 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)?
❑ Yes ❑ No Z Yes ❑ 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 S17,000?
Yes ❑ No ❑ Yes El No
Taxing district Key number 1 Legal description Record number(contract) Page number(contract)
\V-.Oc_R.voyl a(9-l),-o1 -aol- oo\. 35l-0:
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
S) n Luce bra' .ca�il r += Address of applicant (number and street,city,state,and ZIP code)
CO (91 A) RCkCQ S c)t-'‘,(Nce 6,1, 3,N H 7G 7 d
Signature of authorized refr sentati3e 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 TEEGovr' � ge Q f'w, , __
Name of contract seller
FEB 2 3 2023
Taxing district
=SON COUNTY AUDITOR
Key number/legal description
26 -is-67— )-Di -col . 8�i —
Signature of County Auditor Date signed(month,day,year)
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LORRIE LEA HAGAN
- 618 NORTH RACE ST N
PRINCETON IN 47670-1740 W
You are entitled to monthly disability benefits.
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