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Disabilty_Harbison
E R�r� a APPLICATION FOR BLIND OR DISABLED PERSON'S �� COUNTY TOWNSHIP YEAR ? DEDUCTION FROM ASSESSED VALUATION State Form 43710(R13/1-20) -� / Prescribed by the Department of Local Government Finance containedthisICFile Mark Information in document is CONFIDENTIAL pursuant to 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. Name of applicant(owner or contract Yes ❑ 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: eel 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 activit as defined in IC 6-1.1-12-11(d)? LierrY; ❑ 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 r y ar exceed 517,000? Yes , No ❑ Yes No Taxing district Key number/ -6 ri..'•n / Reco number(contract) Page number ont of) Phd 24-Da- ot?,2-- o�. 9 I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Address of applicant (number and street,city,state,and ZIP code) a/ 7 vim. L cz_LA, r d 647644� - Poi</ ignature of authorized representative Address of authorized representative (numtieYand street, city,state,and ZIP code) RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS Name of applicant 410A•b(soyi._ Date filed(month,day,year) jd e./ QL // e E biz•896-5(0i 3 Name of contract seller ii 'IL !13Taxing district � Q/L-A_Lte_ luke.... JUN 12 2023 / Key number I legal des ip on / C ? i��L,duzGC Chi,.vt.4 N .J� �J•J 9 GIBSON COUNTY AUDITOR � 1)3a-btc . ' -©i 8 Signature of County Auditor Date signed(month,day,year) IL Good Samaritan MCV Family Practice Acim riet.,1;11, 406 N. 1st Street Vincennes IN 47591-1340 Dept: 812-885-2750 Dept Fax: 812-885-2756 May 18, 2023 James E Harbison 217 S Main St Hazleton IN 47640 evas0,- cQ RE: Harbison, James MRN: 1286393 Page 1 of 1 11