Disabilty_McCaleb � ir•- APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
A'-' °�' DEDUCTION FROM ASSESSED VALUATION
'•, State Form 43710(R13/1-20) 1 ,JSO/\ Q3
^ i Prescribed by the Department of Local Government Finance ��\�e�n
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 December 31 and filed or postmarked by
or equitat e o 715er, ,If No,what is his.'her exact share of interest? If owned with someone other than spouse,
indicate with whom:
6'4 ❑ 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
eal 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 es ❑ No
Is the property used and occupied primarily for his/her residence? Does the a nt's taxable gro s income or the preceding calendar year
exceed S 7 0 YAW G:.[r]Yes ❑ No %QItr 1.02,3 - El Yes -No
Taxing district Key number/Legal description Record mber(contract) Page number(contract)
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)
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a f authorized represent Address of authorized representative (number and street,city,state,and ZIP code) J
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RECEIPT FOR APPLICATION :r • DUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month.day year)
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Name of contract sell r F IL
Taxing district OCT 0 3 2023
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Key number/legal description Z t t 1.('�2 —00 3• Z/ 4
iiif______50tr_eab 2r��" `YG BSON COUNTY AUDITOR
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Signature of County Auditor Date signed(month,day,year)
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CINDY JO MCCALEB h
812SHARTST
PRINCETON IN 47670-2644 t
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