Disabilty_Lance (2) 1
<pr'-,4.4, APPLICATION FOR BLIND OR DISABLED PERSON'S c UNTY TOWNSHIP ' YEAR
`'a DEDUCTION FROM ASSESSED VALUATION
c ,' State Form 43710(R13/1.20) -y--��" Prescribed by the Department of Local Government Finance Liar) 00 (.J.
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
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer) ((
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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:
❑ Yes ENo
If name on record is different than that of applicant,indicate below: _
Name of contract seller A.7- 241023
Yhi,,h,,,/ d,iLl'fild)
Address of contract seller(number and street,city,state,and ZIFi/g)CN COUNTY AUDITOR Is the property in question:
I Real Property 1 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 Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calen ar ye r
exceed$17,000? i
Yes [ No ❑ Yes No
Taxing district Key nu ber egal description Record number(contract) Page number(ontr t)
tc\J
OU % \()- \LA-1 g-102:000:i-92. -004-- .
INUe certify under penalty of perjury that the above and foregoing information is true and correct.
-
Signature of icant Address of applicant (number and street,city,state,and ZIP code)/L,,,i)3 , it,111
2\\ CokU-4)1\ok Vignature of authorized r presentative Address of authorized representative (number and street,city,state,end Z P code) TA Co '
Notice of Award
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0000329 00032355 2 MB 0.531 0328M3MCS6PI T237 P17 8
8
TIMOTHY LANCE
14 219 E COLUMBIA ST c9
OAKLAND CITY, IN 47660-1503
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