Disabilty_Crittenden *-erA , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
° a DEDUCTION FROM ASSESSED VALUATION
if State Form 43710(R13 i 1-20) c�„ c-�r
Prescribed by the Department of Local Government Finance lJ C-� �f() .L)
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
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Name of applicant(owner or contract buyer)
G?Ak•
Is applicant the sole legal ore itable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
rq�icate with whom:
[
Yes ❑ No
If name on record is different than that of.applicant,indicate below:
D 9 914
Name of contract seller
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Pi011itil01 tNTY Alp
Address of contract seller(number and street,city,state,and ZIP code) G�SS° Is th property in question:
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Isapplicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to ngage 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 applicants taxable gross income for the preceding ca endar ear
exceed$17,000?
Yes ❑ No ❑ Yes No
Taxing district Key n b r/Legal description Record number(contract) Page number con ct)
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
Si nature of applicant Address of applicant (number and street,city,state,and ZIP code) _
ICU& \7 ,V)Nel
Lure of thorized representative Address of authorized representative (number a treet,city,state,and,ZIP code)
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111111.111111111111111.1111111.10011.9111111111...mill
JENNIFER LYNN CRITTENDEN
501 E BROADWAY ST
PRINCETON IN 47670-1845
You are entitled to monthly disability benefits.
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