Disabilty_Pohl (2) . ,E n", APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
°.: DEDUCTION FROM ASSESSED VALUATION
e:.:
• E 7024
•; /► State Form 43710(R1311-20)
'� �48hti.
s�►'' 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
Name applicant(owner or contract buyer)
L
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes [ No
If name on record is different than that of applicant,indicate below:
Fiii E . ..
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP cotfec 1 �" I;t property in question:
utd nr�� � Real Property ❑ Annually Assessed
(.�i 11 Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? S COUNT'? AODfiTP9pplicant disabled and unable to engage in any substantial gainful activity
GIBSON
defined in IC 6-1.1-12-11(d)?
❑ Yes Xo Yes [ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar ar
Xexceed$17,000?
Y s [ No [ Yes)(No
Taxing district Key nu ber/ egal description Record number(contract) Page numberct)
0 7--1-k ( - \0t --SI - 100--06 , -3 -0-.)
.....„
, ,
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signs a of applicant Address of applicant (number and street,city,state,and ZIP code)
Signature of authorized representative Address of authorized representative (numbe)and street,city,state,and ZIP code)
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LISHA DIANE POHL
..1••••
120 W 975 S
HAUBSTADT IN 47639-7805 0,
You are entitled to monthly disability benefits.
01/ •
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