HomeMy WebLinkAboutDisabilty_Fetcher .0 n_h4 APPLICATION FOR BLIND OR DISABLED PERSON'S
COUNTY TOWNSHIP YEAR
:i'`'�-` DEDUCTION FROM ASSESSED VALUATION 1
$r ."i' State Form 43710(R13/1-20) �1^`/
,3,�A Td1 . / V?'`e„'�. Prescribed by the Department of Local Government FinanceoD _
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
equitable owner? If No,what is his/her exact share of interest? If owned wit so on they an spouse,
indicate with who •
❑ Yes ❑ No of
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If name on record is different than that of applicant,indicate below `
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Name of contract seller
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•• - • , umber a • `-et,city,state,and ZIP code) Is property in question:
Real Property El 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 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 ear
exceed$17,000?
Yes ❑ No ❑ Yes No
Taxing district Key nu be /Legal description Record number(contract) Page number( ract)
CO 26— —19 1Oc�-00�.t8Y -00(
AIIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant, , i
,,,. . Iche . Address of applicant (number and street,city,state,and ZIP code)
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Signature of authorized representati Cipi C".. Address of authorized representative (number and street,city,state,and ZIP code)
SOCIAL SECURITY ADMINISTRATION
DISABILITY: DATE OF ONSET 11/7/91 DATE OF ELIGIBILITY 05/1992 .
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OFFICE MANAGER