Disabilty_Embree r�,�•*•4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
.:74) DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) //�
''' Prescribed by the Department of Local Government Finance �=/t‘)Son a3
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.
J .`\ �,• Em b s-e_ye
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:
Lf 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:
L. eat 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)?
(QYes LI No [] 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$17,000?
Yes ❑ No ❑ Yes ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
I/We certify under penalty of perjury that the above and foregoing information is true and correct-2- _O �� _ 00u II
A
Signature=of-applicant` Address of:applicant (number and street,city,state,and ZIP code)
21/
Signal f authorized representative Address of authorized repre emotive (number and str et,city,state,and ZIP code)
LOCI t4 0 iv 1-0
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Name of applicant Date filed(month,day,year)
•
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Name of contract seller
Taxing district APR 2 6 2023
Key number I legal description 2 6.— fn C nUo- (t I 0 14
COUNTY AUDITOR
- coo. 7 -0
Signature of County Au 'tor Date signed
GIBSON(month,day,year)
Notice of Award
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