Disabilty_Stoops " APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
,. '1,:;1,', DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R13/1-20)
y PrescribedDepartment of Local Government Finance
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202-Li .
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
Name of applicant(owner or contract buyer)
140AYCJI\ Sao 9S
Is applicant the sole legal 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:
AN
Name of contract seller
3 0 2014
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Address of c ct sell u or nd street city,state.and ZIP code
P� ( ty. ) GIBS Is the property in question.
yv ON COUNTY gUDITQ Real Property ❑Annually AssessedMobileHome(IC 6-1.1-7)
lin� of ed in IC 12-7-2-21(1)9 Is applicant disabled and unable to engage in any substantial gainful activity
(� 7 as defined in IC 6-1 1-12-11(d)7
i�` _ 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 ar
exceed S17,0009
Yes ❑ No ❑ YesXNa
Taxing districtKey nu ber/Legal description Record number(contract) Page number t)
0 2-49-. Z -00 2.)Sy1-9V-
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature o' pplicant Address of applicant (number and street,city.state,and ZIP code)
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ign ure of authorized presentative Address of authorized representative (number and street,city,state.and ZIP code)
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Notice of Decision — Partially Favorable
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See Next Page
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DECISION
Based on the application for a period of disability and disability insurance benefits tiled on
March 8, 2022, the claimant has been disabled under sections 216(i) and 223(d)of the Social
Security Act beginning on August 1, 2022.
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