Disabilty_Hellums (2) �°t APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
�;;> 1 = DEDUCTION FROM ASSESSED VALUATION
1.« / re State Form 43710(R1419.24) 0 ,(3 1 62 - r25
'm• Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. k4
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
Name o pplicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? If No,what is his/here .ii.r: ;rest? If owned with someone other than spouse,indicate with whom
❑Yes ❑No
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If name on record is different than that of applicant,indicate b w:
Name of Contract Seller lAi``
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Address of Contract Seller(number and street,city,state,and ZI GO.
t Is the Property in Question:
NG
OP 0 Annually Assessed
IA Real Property
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and una,a to e s.*µ 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 r idence? Does the applicant's taxable gross income for the preceding calendar yea exc d$17,000?
Yes ❑No ❑Yes ' No
Taxing District ey Number/Legal Description Record Number(contract) Page Number cont ct)
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
ignature of Applicant 'Address of Applicant(number and street,city,state,and ZIP code) \isZkV)'
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�ignature of Authorized Representative Address of Authorized Representative(number and eat,city,state,and ZI4 code)
Notice of Award
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0000103 00024800 2 MB 0.622 0912M3MCS6PI T166 P17 0
v„ SONDRA D HELLUMS
1837 W BURLINGTON PL o
PRINCETON, IN 47670-9332