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Disabilty_Harrell T7 4 APPLICATION FOR BLIND OR DISABLED PERSON'S d�' : \ DEDUCTION FROM ASSESSED VALUATION couNnr TOWNSHIP YEAR •� '�� I ,r= a'. ,e State Form 43710(R13/1-20) le 2-1 �° --'�'' Prescrib ed bed by the Department of Local Government Finance cy2_4;t Son Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark a 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 appt . JI(owner or contract buyer) , / l 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 V IC\‘..)-V*).9 7/ lib "'Lk `-'4 MP�1� ).,,,,d Address of contract seller(number and street,city,state,and ZIP code) /, OR N �p�( s th roperty in question: S% P Real Property ❑ Annually Assessed SO1}11440N GO Mobile Home(IC 6-1.1-7) Is applicant blind as defined in IC 12-7-2-21(1)? Goa Is applicant disabled and unable to engage in any substantial gainful activity as defined in IC 6-1.1-12-11(d)? ❑ Yes XNo 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 ear exceed$17,000? Yes ❑ No ❑ Yes No Taxing district Key nu er/ egal description Record number(contract) Page number ont ct) a 2,S1 . lki °�-�3 - © -0Z � 0oz . �3 2 . I/We certify under penalty of perjury that the above and foregoing information is true and correct. Signature of applicant Address of applicant (number and street,city,state,and ZIP code) 1?4,141-- V: /761/14'Elf ignature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code) y,,.i 'I',0- ' - . �. '' 1l. ROBERT V HARRELL II I i'. 311$PRINCE AT it PRNCETON,IN 17470411$ y i '`y i . r / , , ' r •i ` �` r t � � t , r i ' I / '