Disabilty_Petitjean '. s�; APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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�' DEDUCTION FROM ASSESSED VALUATION
l'`t1 ,.a�u State Form 43710(R1311-20)
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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
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Is applicant the sole legal or equitable owner? J If No,what is his/her exact share of int:k ' If of - 1,ith someone other than spouse,
i di ., ith whom:
❑Yes ❑ No
If name on record is different than that of applicant,indicate below: 01 2 C 9Z4
Name of contract seller � -f J/l�
% COUNTY AUDITOR
GIBSON
Address of contract seller(number and street,city,state,and ZIP code) Is the operty in question:
eal Property ❑ Annually Assessed
V 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 cale ar ear
exceed$17,000?
Yes ❑ No C YeskNoTaxing district Key num er Legal description Record number(contract) Page number
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IIWe 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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Signa ure of authorized represen ive Address of authorized representative (number and stree),city,state,and ZIP code)
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-- HAROLD LEO PETITJEAN
12768 S COUNTY RD 200
HAUBSTADT IN 47639 0
You are entitled to monthly disability benefits.
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