Disabilty_Selby �E=R^,z•� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
A • A. DEDUCTION FROM ASSESSED VALUATION ` - -
State Form 43710(R13/1-20) G(6 Soh M�WQ J gq
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 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 applicant(owner or contract buyer) [�
Alaf—i t L 5e( j
Is applicant the sole legal or equip, e owner? If No,what is his'her exact share of interest? If owned with someone other than spouse.
rr- 'es indicate with whom:
fires ❑ 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 the property in question
teal Property ❑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)?
Kies ❑ No �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$17,0007
Ld Yes ❑ No ❑ Yes 2 No
Taxing district
Key number/Legal description Record number(contract) Page number(contract)
IkOn• �ca���er� (26-t o- 3(o -1-(O0- 00/. oil
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of plicant Address of applicant (number and street,city state,and ZIP code)
Li a l0 5 700 w ( ujUk5\\\fie � Li 7
Si ' r f authorized representative Address of authorized representative (number and street.city,state.and ZIP code)
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RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
lNGr L 5 e I b uv
Name of contract seller) FILED
Taxing district
\(( FEB 0 9 2024
Key number/legal description
- U- (P _ ',D D OIBSON COUNTY AUDITOR
Signature of County Auditor Date signed(month,day,year)
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