Disabilty_Braselton i
k APPLICATION FOR BLIND OR DISABLED PERSON'S
1COUNTY I TOWNSHIP YEAR
/ .-./ ' ``'' DEDUCTION FROM ASSESSED VALUATION .
V` _
State Form 43710(R 13 f 1-20)
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'� Prescribed by the Department of Local Government Finance 4COid
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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 g'i -nt(owner or contract buyer
6 IftkY I ,I 2--LV id ( )
Is applicant the sole local or equitable owner" !if No.what is his'her exact share of interest" If owned with someone other than spouse,
indicate with whom:
Yti p
Yes ❑ No FILE
If name on record is different than that of applicant,indicate below'
OCT 2 3 2024 6
Name of contract seller
Acivi as iiiray,&4)
Address of contract seller(number and street.city.state,and ZIP code) Is the proper , a., a,
Real Property ` Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC t2.7-2-21(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 u 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"
Yes = No E Yes SA/No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
OAF R/t)&ThJ 4-itit-0108-ovi10- 001S
Me 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 ZI c e)
om'
54
So ? I -t Xikt 6E.Thk) 1)041610
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Signature of authorize.; epresentatrve Address of authorized representative (number and s reet,city,state.and ZIP code)
G`P1 SEC4,�
'�,USA�'` Social Security Administration
.76 IIIIIU { Benefit Verification Letter
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ROBERT JOSEPH BRASELTON
308 10TH STREET
0
PRINCETON IN 47670-1130 N
You are entitled to monthly disability benefits.