Disabilty_Bridgewater o� ' , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
�; .. 2. 1 DEDUCTION FROM ASSESSED VALUATION
rt,,.gif State Form 43710 R1311-20 NIQ
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•L ' 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. n
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located. / 1�,3—
Filing Date: Form must be completed and signed by December 31 and filed or postmarked
Name of applicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spou \
indicate with whom:
Yes [ No
If name on record is different than t t o pplicant,indicate below:
F IL E IF
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Name of contract seller
JAN 0 12025
Address of contract seller(number and street,city,state,and ZIP code) Is the roperty in question:
Real Property ❑Annually Assessed
a Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? ' teli*Nt)"$AtJE6 ngage in any substantial gainful activity
me 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 calendar y ar
exceed$17,000?
Yes [ No ❑Yes No
Taxing district Key nu er l egal description Record number(contract) Page number( o ract)
00., . 2 - e -02 ;0 0 0- 5 -00 .3
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INVe certify der p- alty of perjury that t - a$ov- . d foregoing information is true and correct.
Signa Address of applicant (number and street,city,state,and ZIP code)
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igna re of authors epresentative Address of authorized representative (nurnder and street,city,state,and ZIP code)
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CARLA JEAN BRIDGEWATER
PO BOX 1453
LEXINGTON TN 38351-0G29
Your Social Security benefits are paid on or about the third V
month.
We found that you became disabled under our rules on May
Information About Past Social Security Benefits