Disabilty_Dix 1. 2. A
:# APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
`ci. DEDUCTION FROM ASSESSED VALUATION
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r l -,•t/.,. pi d; ;,; State Form 43710(R13!1.20)
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e%� 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
rNa o applicant(owner o tract buyer)
J a In
Is ap ' • ' ' = uitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
[ Yes _. No
If name on record is different than that of applisant,indicate below:
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Name of contract seller MAY 2 5 2023
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Address of contract seller(number and street,city,state,and ZIP code) z.tr/ a , I the property in question:
GIBSON COUNTY AUDITQ
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 Yes 1 No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding Galen ar ear
exceed S17,000?
Yes ❑ No _ Yes No
Taxing district Key nu e /Legal description Record number(contract) Page number/on act)
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
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Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
La 0 L° i )-1S Pt-Ipoild, , 3i-1-( 76(1E.
gnatu of aut ze re s ' we Address of authorized representative (nuer and street,city,state,and ZIP code)
1111111.11• Notice of Award
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mom 4180 W 850 S .0
. FORT BRANCH, IN 47648-8166 x
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