Disabilty_McEllhiney (2) 00-,,,,. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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DEDUCTION FROM ASSESSED VALUATION Po..VO 0.
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.. State Form 43710(R13/1-20)do,
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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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See reverse side for additional instructions and qualifications. * I-
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If name on record is different than that of applicant,indicate below:
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Name of contract seller
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Address of contracseller(number and street,city,state,and ZIP code) Is theypperty in question:
c '"------ , PS Real Property Ell 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)?
0 Yes V‘o [i2‘E] No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
p4/6.6 1=1 No 0 Yes
Taxing district district Key number/Legal description Record number(contract) Page number(contract)
Polasa. \ 0,3,._... .....,.._ au) - 1/4 -0q- - 00- 00 , _ 0- 3.--(Q --
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I/We certify under penalty of perjury that the above and foregoing information is true and cOrrect.
Signature of applicant ( Address of applicant (number and street,city,state,and ZIP code)
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Signature of authorized re resentative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date tiled(month,day,year)
INC\a_C\ )(Nfa e_1( k-‘ kme;$ • FILED
Name of contract seller
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JAN 0 1 2025
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Taxing district
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Key number/legal description GIBSON COUNTY AUDITOR
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Signature of County Auditor Date signed(month,day,year)
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Pcv-0-0.(Nol,Li_a . 33AAL.,,,,,,_.0) ,,,,,,o . ) -D-Q .
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Notice of Award
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You are entitled to monthly disability benefits beginning January 2025.
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