HomeMy WebLinkAboutDisabilty_Bethel ,),,,fn APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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'' State Form 43710(R13/1-20)
R'' � CI';e1b Prescribed by the Department of Local Government Finance `�'�
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
Is applicant the so a egal or equitable owner? If No,what is his:her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑ Yes 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 e operty 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)9 Is applicant disabled and unable to a gage in any substantial gainful a tivity
as defined in IC 6-1 1-12-11(d)?
❑ Yes o Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calen ar y r
exceed S17,000?
Yes ❑ No ❑ Yes o
Taxing district Key nu ber Legal description Record number(contract) Page number( ntra
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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 horized pr ntative Address of authorized representative (number and street,city,state.and ZIP code)
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DOROTHY JUNE BETHEL W
602S HALL ST N
PRINCETON IN 47670-2328 t