HomeMy WebLinkAboutDisabilty_Wirth (2) .0_,_ % APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
i. DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) (� '' Prescribed by the Department of Local Government Finance `--�On On 1-.I
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
Name of applicant(owner or contract buyer) ��
Cry\eS (ZI .
Is applicant the sole legal or equitable ow er? If No,what is his/her exact share of interest? If w d ith so ne other than spouse,
in - to ith wh
X
es ❑ No //)��■
If name on record is dffferent than pplica icate below 4 AR
Name of contract seller ��j3W
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CO NAY
Address of contract sel r(number and y state,and ZIP ) I the ro "�f lion:
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)7 'Is applicant disabled and unab a to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes Alo Aes ill No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding caler
exceed$17,000?
Yes ❑ No ❑ Yes No
Taxing district Key nu ber egal description Record number(contract) Page number(contr ct)
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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)
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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 PILED
Name of contract seller
APR 1 2 2024
Taxing district
Key number/legal description C:IBSON COUNTY AUDITOR
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Signature of County Auditor Date sig ed(month,day,year)
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CHARLES HOBART WIRTH
414 E OHIO ST
PRINCETON IN 47670-3026
You are entitled to hospital insurance undekMedicare beginning January 1995.
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