Disabilty_Washburn Jr R, .,. APPLICATION FOR BLIND OR DISABLED PERSON'S
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State Form 43710(R13/1-20) ,, ,/��./7
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Prescribed by the Department of Local Government Finance �`1ps�n V s? \oay
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
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Is applicant the the soie legal tyr eduitable owner? I If No,what is bis'her exact share of interest'? If owned with someone other than spouse.
indicate with whom:
TA/Yes ❑ No .
If name on record is different Than that of applicant,indicate below:
1
Name of contract seller
Address of contract seller(number and street city.state.and ZIP code) Is the property in question
AReal 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)?
❑ Yes XNo `g Yes ❑ 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?
XYes ❑ No • ❑ Yes XNo
Taxir district Key number/Legal description Record number(contract) Page number(contract)
VA/AfC1-0 id
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant I Address of applicant (number and street.city state.and ZIP code)
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gnature or air'o ffad representatwe 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 ofe contract
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Taxing 'riot /
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Key number(legal description /I Q 41)2,c/ C�/i ,,{i�_,1.___)
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Signature o`County Auditor O Date signed(month,day,year)
Notice of Award
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0000199 00022046 2 MB 0.622 0819M3MCS6P1 T147 P15
r LARRY J WASHBURN JR
1215 SOUTH WASHINGTON o
PRINCETON, IN 47670-2933 .
AUG 3 U 2024
C See Next Page 1f2,-;Aitd T. J41z` TOR
GIBSON COUNTY AUDITOR (/