Disabilty_Hedge • N. r.c APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR _
�i -1\, DEDUCTION FROM ASSESSED VALUATION
VC
'• ' State Form 43710(R13/1-20) I
Prescribed by the Department of Local Government Finance �Q� J-?—Al
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
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Name of aguirowner or contract• .:
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Is applicant the sole legal or eqN �r? If No,wha' ,is'her exact sh e or _ T If owned with someone other than spouse,
—�� zit indicate with whom
Yes ❑ No
If name on record is different than that o`-;plicant,indicate below:
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Name of contract seller 6/es MAY
NCpUN
Address of contract seller(number and street.city.state.and ZIP code) VOR/tO t property 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)7 Is applicant disabled and unable to en e in any substantial gainful activity
as defined in IC 6-1 1-12-11(d)?
❑ Yes Ao Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxab:e gross income for the preceding calen ar y ar
exceed$17,000?
Yes ❑ No ❑ Yes No
Taxing district G �, �7 Key nu. er/ egal description Record number(contract) Page number o ract)
/)�J�J`/ 26-12-01 -20) -0o0 .01-028 .
I/We certify under penalty of perjury that the above and foregoing information is true and correct
ignature of applicant Address of applicant (number and street.city state,and ZIP code)
natu of gut• epresen alive Address of authorized representative (number and street,city.s te.and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERS
Name of applicant Da(�'ith.day year)
1—k...0--4_ .
Name of contract seller /f .'�
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d;???'-0 r*--.f - 1 eo
Taxing district SO ZQ
C) Li ' N couN
Key nu er/legal description ���/
_I1—CD1 '-2/ 1 _0 00, 6 g - 0 2___SI 0R
Signature of County A r Date si ed(mo th,day,year)
Notice of Award .
MIME
Great Lakes Program
Service Center
600 West Madison Street
= Chicago, Illinois 60661-2474
Date : May 14 , 2024
BNC# : 24M1724C22049-A
I'IIIIiI"IIIIIIl'InII'III"I'IIIuIiIIIIIi1'ii'III"Iilili'I'I'
KERIJEAN HEDGE
214 EAST WALNUT STREET
PRINCETON IN 47670-1764
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