Disabilty_O'Dell . \ APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY I TOWNSHIP YEAR
4` DEDUCTION FROM ASSESSED VALUATION
%' State Form 43710(R13/1-20) 3 0 210
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Prescribed by the Department of Local Government Finance
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
Name of applicant(owner or contract buyer)
n°V f�
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I5 eon ca.::thesole!eg c,i4
equitable o nern 'If No,what is hls'iier e a s 1 e Intefe If owned with someone other than Sp0U5',
indicate with whom:
e5 _ No i p
If name on record is different than t t of pplicant,indicate below' /� zo
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GiLis2ereee-(Name of contract seller COUNT Q ,
Address of contract seller(number and street,city,state,and ZIP code) I l e property in question -
Real Property 1 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 5-1 1-12-11(d)?
Yes No Yes D�No
Is the property used and occupied primarily for his/her residence', Does the applicant's taxable gross income for the preceding cal Al year
exceed 517,0007
Yes I No E Yes No
Taxing district Key n berI ega!description Record number(contract) Page number contract)
07/0 .
26.- O' 4- 30Y 000. IS1 v
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
signature applicant Address of applicant (number and street.city state,and ZIP Code)
0414.4440U 01 0# 0 \ic-ne . Nicitk, r
._
Signature of authorized repr .,',a:we Address of authorized representative (number andstreet,city state,and ZIP code)
Notice of Award
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