Disabilty_Carroll .5,= f APPLICATION FOR BLIND OR DISABLED PERSON'S
o��r��•. ,� COUNTY TOWNSHIP YEAR
. � V. DEDUCTION FROM ASSESSED VALUATION
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11�:.,;1;' State Form 43710(R13/1-20) I
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%. Prescribed by the Department of Local Government Finance
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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 by the following January 5 of the calendar year in which the
property taxes are first due and payable.
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Name of icant(owner or contract buyer)
• ' Cpin(Y\ t0
Is applicant t 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:
E. Yes ❑ No
If name on record is different than that of applicant,indicate below: NOV 2 2 2024
Name of contract seller
GIBBON Cn LINT�����`�
Y AtY' t�t�
Address of contract seller(number and street,city,state,and ZIP code) " Is h 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 No Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendary ar
exceed$17,000?
Yes ❑ No ❑ Yes o
Taxing district Key nu ber/ gal description Record number(contract) Page number(contrac)
0 , ,,,,,,,,,,...—. A-1 ir36^ tee '—00171S-1 2R— .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Snature�l Address of applicant (number and street,city,stat an ZIP code)
I W SD J S 11 r On '� )
Sig ature of authorized r presentative Address of authorized representative (numb&and street,city,state,and ZIP code)
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T10 PO**SNGLP 174336-10-11-1 -4146 BEV 1101
DAVID DEWAYNE CARROLL
4..
rzli• 591 W COUNTY RD 350 S
PRINCETON IN 47670
004146
You are entitled to monthly disability benefits.
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