Disabilty_Knoll '0;;34 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY 1 TOWNSHIP YEAR
I DEDUCTION FROM ASSESSED VALUATION
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',-: .:^ ' State Form 43710(R1311-20) /�; /'
a .; Prescribed by the Department of Local Government Finance v 3 ((//!v1�
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 ontract buyer
Nrve.is
noll .
Is applicant the sole legal or epuitable owner? l If No,what is his!!her exact share of interest? If owned with sonit
th i i.n "se,
indicate wilin/+whhom:
❑ Yes ❑ No CT� ',
If name on record is di�erent than that of applicant,indicate below' 0
cues ��
NcoUA,...q
Name of contract seller
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Address of contract seller(number and street,city,state.and ZIP code) Is he repels),in question
eel Property _ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7.2.21(1)1 Is applicant disabled and unabl_to en age in any su tial gainful activity
as defined in IC 6-1 1-12-11(d)?
Yesk Yes o
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the prece 1 g calend r y r
exceed S17,000?
Yes _ No ❑ Yes No
Taxing district Key nu er t egalnl description Record number(contract) Page number(c ntr t)
ccl-
llWe 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 ZIP code)
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INA" 0 . .\ 0 k tkj Ci '3--' f).1,,,e,. .. .
Signature of authorized representative Address of authorized representative (number and street,city.state.and ZIP code)
5==:
MEM
5E= 4,0, ..d1440,1111ifilh.Whilvheinisdha
emem ciiAliLKS DONALD KNOLL,
730 S P'RANKLIN SI
OAKLAND CITY IN 1.7660.1628
You are entitled to monthly disability benefits,