Disabilty_Brewer ;c^•r•� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
_ DEDUCTION FROM ASSESSED VALUATION
''''‘'it‘. eia ' State Form 43710(R13/1-20) I 1 s� ^v
.) Prescribed by the De artment of Local Government Finance C 1 rtnceArti
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
Name of applicant(owner or contract buyer)
\ G oh L- re jet—
Is applicant the sole legal or equitable owner? If No,what is hislher exa:t 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 the property in question
❑ Real Property ❑ Annually Assessed
/ Mobile Home(IC 6-1.1-7)
Is applicant blind as defined incI 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)?
(gges No ❑-Yes ❑ No
Is the property used and occupied primarily for his/her residence's Does the applicant's taxable gross income for the preceding calendar year
� exceed 517,000'/
1�, res ❑ No ❑ Yes 21Cic
Taxing district Key number/Legal description Record number(contract) Page number(contract)
‘"A (\Le-k-c2v1 _ab-) -og- DO3-(70I . 23"3-oaz
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
71144 font Address of applicant (number and street,city state,and ZIP code)
n — Vtdy L kA,9Ior Ave V"C-ekkl 1{�� 10
Si t e f aut oozed 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)
3c..50n L ret.✓er
Name of contract seller
Taxing district FILED
P r o con
D
Key number/legal description MAR 1 1 /
2024 V
a4-Iz- o5-103_e30/. $73-0aY > >
Signature of County Auditor Q'eiskuv.... 6u,..1 jci........._ na Q year)
COUNTY AUDITOR