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4t''�c�' APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
*: .'1 DEDUCTION FROM ASSESSED VALUATION
L,L),,,,::,,,‘ State Form 43710(R14/9.24) C30n , daYf�O2C
Prescribed by the Department of Local Government Finance
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 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 or contract 1'% OLVef .buyyer)
Is applicant the sole legal or equitable owner? If No,what is his/her exact share or interest? If o ed ' s eone th t i se,indicate with whom
❑Yes ❑No
If name on record is different than that of applicant,indicate below:
MAY 13 2025
Name of Contract Seller
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Address of 'eller(number and street,city,state,and ZIP code) Is the Prop @LINTY AUDITOR
0 Annually Assessed
�(� Real Property Mobile Home(IC 6-1.1-7)
Is.►+li.'t blind as defined in IC 12-7-2-21(1)? Is applicant disabled and una a to in any substantial gainful acuity as defined in IC 6-1.1-12-11(d)?
❑Yes 7) o Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar yea ex eed$17,000?
►:iYes ❑No ❑Yes o
Taxing District Key Number/Legal Description Record Number(contract) 'Page Number(c t ct)
OOf 3-\q_7J0 --( o , 2 f ,0 0 .N—
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
1 ignature of Applicant Address of Applicant(number and street,city,state,and ZIP code)
4.011,,20, 1 1. Qeidfri&__ () () A S ' eery S -Y-L
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Signature of Authorized Representative Address of Authorized Represen I:(number and street,city,state,and ZIP code)
°1 ^ - Social Security Administration
% o Benefit Verification Letter
0033,32
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17 P1 179411-10-11-1-3332 BEV 0411
MAR205 S GRLA F EEON SWENT c
FRANCISCO IN 47649-0018
0033,32
�� You are entitled to monthly disability benefits. MAY 13 2025
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