Disabilty_Small ,: ResetForm
4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
0..,,'- DEDUCTION FROM ASSESSED VALUATION
. ._ ,�� State Form 43710(R14/9-24) ADI'^ a 5
ism Prescribed by the Department of Local Government Finance - I
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,signed, and filed by January 15 of
e t ao(1 R . StatC
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
s ❑No
If name on record is different than that of applicant,indicate below:
Name of Contract Seller
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Address of Contract Seller(number and street,city,state,and ZIP code) Is the Property in Question:
t ❑ al Property ❑Annually 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 es ❑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?
lloirs.......
0 No ❑Yes I-ldQir-
Taxing District Key Number/Legal Description I Record Number(contract) Page Number(contract)
Oculda,Na -t au- i -l cC -( na-co 1 -olsktir-007
I/We 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)
/,�y4' ,-- v` 3 a . "Tr L< _f.. O ra-7. - A
Signature of Authorized Representative Address of Authorized Representative(number and street,city,staid and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of Applicant Date Filed(month,day,year)
E. - pie
Q FILED
Name of Contract Seller—Nt
ce . e'e:b FEB 0 3 2025 .-.
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az - 1�-\°�.-\ OD- 001-dog- CCU .
y Number I Legal Description l,/l 414Z a. J/Y I�72d/
GIBSON COUNTY AUDITOR
Signature of County Auditor Date Signed(month.rf\i,p_tr.,61_g___Q a .u.)34-t -t,zi eitka r\ - -- -a
,day,year)
a
T5 P1 176802-7-3-1-2700 BEV 0121
'� . ELDON R SMALL
iti 223 E TRUSLER ST
OAKLAND CITY IN 47660-1835
002700
Type of Social Security Benefit Information
You are entitled to monthly disability benefits.
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