Disabilty_RIley ‘ 4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
1. ,:,.f DEDUCTION FROM ASSESSED VALUATION
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�1 i' State Form 43710(R 1311 20) (0 I/1 C )1
Local Government Finance ,13 .
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(..' 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.
Name of applicant(owner or contract bu r)
° 0 $ e_ ( tra 3 „( -
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Is applicant sole legal •r e.uitable owner? If No,what is his/her exact share of interest? If owned h eon other than spouse,
indicate with om:
❑ Yes ❑ No O0J, .
If name on record is different than that of applicant,indicate below Cyr to46
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Name of contract seller CoGQJ/
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Address of contract seller(number and street,city,state,and ZIP code) Is pro', f question:
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 una le 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 cal dar ar
exceed$17,000?
Yes ❑ No ❑ Yes No
Taxing district Key nu er egal description Record number(contract) Page number(cont t)
26-2o- c9 - COO-0O o.Lo- I-on I .
IIWe certify under p- alty of perjury that the above and foregoing information is true and correct.
Signa're of appVZ Address of applicant (number and street,city,state,and ZIP code)
. i�� 7731 r S TO S t r— �,. ,. Dh-4�64
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natur- • : r' ized represe, .tive Address of authorized representative (number and street,city,state,and ZIP code)
11111
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GEORGE LOREN RILEY JR W
7751E550S o
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FRANCISCO IN 47649-9129