Disabilty_Evans n^•,��\
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
' DEDUCTION FROM ASSESSED VALUATION1
' State Form 43710(R13/1-20) G t\OSpyA (1 0
4 , /' Prescribed by the Department of Local Government Finance �� 11 .!
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
A - \22 L' vGn5
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:
COIa Yes No
If name on record is different than that of applicant,indicate below'
Name of contract seller C 0 NTRAC-I-
? - cc V G✓\oven
Address of contract seller(number and street,city,state.and ZIP code) Is the property in question
[ 1'1--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)n
❑ Yes ErNo t- res ❑ 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 S17,000? ,/
! s [I] I No ❑ Yes No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
?ri n ce f oy, .G-ID-Ol_a 01- pa i/. 3413-c
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)
9/( s Hail 5 - ?rk nce ,- ,rl Lf7(, 70
Signature of autho ized 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)
NSle.(' �`2 E�
Name f contract seller
?G.r clC VCs0 0Veil GGNITRAC T
Taxing district FILED
1Pr.\rce4on
Key number/legal description MAR 2 8 2024
o?G- p �-O-7-'O/ - poq . 34/3-08
Signature of County Auditor DaApeobiggeha. i 24 ndI
ii• .A e l �A / GIBSON COUNTY AUDITOR
CD
ED
II.III.IIIIIIIIIIIIIIII.111111II11IuiII11IIIIIIIIIIIIIIIIIIIIIIII .L7
ANSLEE DENISE EVANSt.
620 N SEMINARY ST o
PRINCETON IN 47670-1746
You are entitled to monthly payments as a disabled individual.
Date of Birth Information
.
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