Disabilty_Mullins Jr .,( ?
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s"E�,""''� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
tr DEDUCTION FROM ASSESSED VALUATION
6. /� State Form 43710(R1419-24) 66e6/d K4 44
lam Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. Al
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,signed,and filed by January 15 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Name of Applicant(owner ontract bu er)
\._:1 illilltES ' DILI Ai s ,lt
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If owned with someone other than spouse,indicate with whom
)(Yes ❑No
If name on record is different than that of applicant,indicate below:
Name of Contract Seller
Address of Contract Seller(number and street,city,state,and ZIP code) Is the 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 Xo Yes ❑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?
Yes ❑No ,s i No
Taxi District Key Number/Legal Description Record Number(contract) Payo Numbe ant ct)
RIAieD7Old d a -1r- r ,-Dot/r a
� a� � Rio '�3 �7
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signet lc\of Applicant Address of Applicant(number and street,city, to e,and ZIP code)
''NL6.A '3 ii\m , RiAlob-Z/Lis' 4) 47�7f Authorized Re resentative Address of Authorized Re resentative and street cit state and ZI code)
p p (number �city, �
°~.
You are entitled to monthly disability benefits.
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