Disabilty_Polach APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a ,, DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R13/1-20) Gibson Owensville 2023
b 4 J' 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 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 appl'cant(owner or contract buyer)
Louis E Polach
indicate with whom
m Yes ❑ No
If name on record is different than that of applicant,indicate below:
Name of contract seller
N/A
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
®Real Property ❑Annually Assessed
N/A 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 ❑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$17.000?
®Yes ❑ No ❑ Yes ®No
Taxing district Key number/Legal description Record number(contract) I Page number(contract)
Owensville 26-17-12-102-000.369-022
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)
ofr 518 W Brummitt St., Owensville, IN 47665
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day,year)
Louis E Polach FILED
Name of contract seller
N/A OCT 27 2023
Taxing district ` ,— -\
Owensville ' L _
Key number/legal description ` N
n
GI / CBSON COUNTY AUDITOR
26-17-12-102-000.369-022
Signature of County Auditor Date signed(month,day,year)
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LOUIS ELLIOT POLACH
1234 NEGLEY AVENUE o
= EVANSVILLE IN 47711-3564
You are entitled to monthly disability benefits.
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