Disabilty_Urbanek osp , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION r 1
a State Form 43710(R13/1-20) f7'C.. ,J—J Prescribed by the Department of Local Government Finance LSOn 21 .
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.
Se verse side for,additional instructions and qualifications.
Name of a licant(ow er or contract buyer)
fan o6vt (-) 4°\nek
Is applicant th s 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) Is e roperty in question:
Real 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 toe age in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes No Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding cale dar ar
exceed$17,000?
Yes El No ❑ yes No
Taxing district Key nu ber Legal description ' Record number(contract) Page number(contr t)
0211 • 26-11—10k— 001' Cel .• 0 2-() .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Si of applicant Address of applicant (number and street,city,state,and ZIP code)
71 t. pylbk C e 0 1 �l o\n h 1 iN— IN(C)i)°r J )-9Ck,S2
ture of authorized representative Address of authorized representative (number and let,city,state,and ZIP code)
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9 iiiiIIi,IIuIi111111IIIituIIIIIi1.1111uuu!hill iiuIII11119I'I
JAN MICHELLE URBANEK
MB 903 MOHAWK DR
FT BRANCH IN 47648-9508
)
FILED
You are entitled to monthly disability benefits. MAR 2 2 2024
Y'h,ciutzl a �
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