Disabilty_Douglas III ReseAi
orgy APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
4--411 DEDUCTION FROM ASSESSED VALUATION
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: State Form 43710(R1419-24) I Q2L 111
111. Prescribed by the Department of Local Government Finance .J
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
Na e o Applicant(owner tract buyer)
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Is applicant the sole legal or e ' e owner? If No,whams nisi►,wr 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 Se 'LED
Address of Contract Sellerayer sT sl 5ity,state,and ZIP code) Is the roperty in Question:
Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as de ned,in IC 12-7-2-21(1 ?t0 Is applicant disabled and una a to gage in any substantial gainful activity as defined'n 16-1.1.12-11(d)?
GIBSON COUNTY AUDITOR)Yes No es ❑No
Is the property used and occupied primarily for hislher residence? Does the applicant's taxable gross income for the preceding calendar y r exc d$17, 00
es 0 No 0 Yes o
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Taxing District 011—
ey Number I Legal Description �InRecord Number(contract) Page Number( ntra )
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sign f Ap li , Address of Applicant(number and street,city,state,and ZIP code)
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Signature of Authorized resentative Address of Authorized Representative(number and street,city,state,and`ZIP code)
Notice Of Award
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0000319 00023598 2 MB 0.622 1220M3MbS6P1 T163 P16 •
W DOUGLAS
gr. PO BOX 582 • 0
OWENSVILLE, IN 47665-0582
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