Disabilty_Basham - APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY
TOWNSHIP I YEAR
di 4 DEDUCTION FROM ASSESSED VALUATION
a State Form 43710(R 13/1-20) �°
�: _' Prescribed by the Department of Local Government Financele) .��
information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
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 contact r)
r; el, \ 4AcIfYis
Is applicant.,a sole legal or equitable owner? 'If No,what is his/her exact share of interest.? If owned with so the -pcuxe.
ind -'a with whom:
Yes • ❑ No I -`ip /f 9
If name on record is different than.that o,applicant,indicate below: . 204
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Name of contract seller
Address of contract seller(number and street,city.state.and ZIP cede) I th 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)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1 1-12-11(d)?
❑ Yes ANo Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cale,,dar ear
exceed 617,000?
Xes Ell No ID Yes )� No
Taxing district Key nu er\Legal description Record number(contract) Page number(cont ct)
02,:3, - 2_6, 12"18 -102- Ooo. itx 02s .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
.4011,
Sign- re of a.plica`- r I Address of applicant (number and street.city.state,and ZIP code)
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ignature of authorized representative I Address of authorized representative (number and street,city state.and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of appli _ Date filed(month,day year)
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Name of contract seller
Taxing district
111111
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Key number/legal description
C 12-1 --- 102- OoO -C - DIE -
Signature of County Auditor ` t j Date signed(month,day,year)
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DANIEL RAY BASHAM i , :
1117 SOUTH PRINCE ST G/eS w
PRINCETON IN 47670-3011 bC Q 1� w
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