Disabilty_Hyatt ,, 4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
i °' DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20)
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File Mark
e16 a Prescribed by the Department of Local Government Finance
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
/
Name of applicant(owner or contract buyer)
� �oram. V\O-A-kr n
is app cant the sole legal or equitable owner? If No,wha'is s.'her exact share of inter st7 If owned with someone other than spouse,
indicate with whom:
fi....Ygr.❑ No
If name on record is different than that of applicant,indicate below'
Name of contract seller
P
Address of contract seller(number and street,city.state,and ZIP code) Is the pro rty 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)7 Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1 1-12-11(d)?
❑ Yes to es ❑ 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 S17,000?
es ❑ No ❑ Yes Iktri
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Pr l tce..._ -cam ..1io -i a-o- H-oa . to�- -
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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Signature of authorized representative Address of authorized repres ative (number and street.city state. ZIP code) l
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RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
Name of contract seller 3 J FILED
Taxing di i�t( pr .
O C T 2 4 2023
L.rtyr , r\( e //lcC'./1t1 Cam:.Ge Pr'1 7 a,
Key number/legs description
GIBSON COUNTY AUDITOR
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Signature of County Auditor Date signed(month,day.year)
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You are entitled to monthly payments as a disabled individual.
003447
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T7 P1 163054-10-3-2-3447 BEV 1012
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NORA KATHRYN HYATT -414
PO BOX1164 k
003447 PRINCETON IN 47670-0864
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