Disabilty_Wirth f 5- APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
3'• !'1 State Form 43710(R13/1-20) `/�� n
* uni. Prescribed by the Department of Local Government Finance `� .s0'n O v/^2
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)
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Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with m ne of th n Ouse.
indicate with whoa
Yes ❑ No
If name on record is different than at applicant,indicate below OR
12 2024
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Name of contract seller O4 --c Q
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'4Up„,.r) iJ
Addres c act sell u� and; a,city,state,and ZIP code) Is the property in question:41
�\ 1 ❑ Real Property ❑ Annually Assessed
MobitE Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)9 Is applicant disabled and unable to engage in any substantial gainful activity
XI()
as defined in IC 6-1.1-12-11(d)'
❑ Yes Yes -❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar ear
exceed$17,0007
Yes ❑ No ❑ Yes No
Taxing district 0-2__cs
Key nu er Legal description Record number(contract) Page number(coot ct)
26 ^i2- i 4-lOy -001.06s-022 .
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)
Signature of authorized 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)
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Name of contract seller
Taxing district 4 Pi? ,2
O ZF - ...5' • 202#
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Key number/legal description OH
Signature of County Auditor Date sired(month,day,l ar)
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BRIAN MATTHEW WIRTH
1213 S PRINCE ST
PRINCETON IN 47670-3013
You are entitled to monthly disability benefits.
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