Disabilty_Hartley .�,-R,,.. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
�• DEDUCTION FROM ASSESSED VALUATION
S ' State Form 43710(R13/1-20) r�u
G rJ sore C;rice I
• Prescribed by the Department of Local Government Finance `� /
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 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)
P40,-v- A kiQs*kt.,
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:
Name of contract seller
Address of contract seller(number and street,city,state.and ZIP code) 1 h roperty 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)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1 1-12-11(d)?
cies 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 year
exceed$17,0007
L_I Yes ❑ No El Yes EI 1Go
Taxing district Key number/Legal description Record number(contract) Page number(contract)
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cs , ,w °k-. la-a,- you- Az.5.-yti-c,?&
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
nt Address of applicant (number and street,city.state,and ZIP code)
G's�� 2 S Sew l rl a� 5 Pce(a�'► L y�,/V `� 70
Signature of authorized repr entati Address of authorized representative (number and treet,city,state.and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
mcA4-`i- A 1kc ear Vei
Name of contract seller
Taxing district FILED
k (\CP-} MAR 11 2024
Key number/legal description
.Z-( -0-7- 903--C . S 20 -va W' AeAtte C am )
Signature of County Auditor WAS Xa�t )TIDR
M „A I.V7
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