Disabilty_Koch A •i/
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
' DEDUCTION FROM ASSESSED VALUATION
OIf. = State Form 43710(R13/1-20)
ici Prescribed by the Department of Local Government Finance
1,)oi004- 702,r
File Mark
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 and signed
Name of applicant(owner or contract buyer) 1LED
Pi D
dot L6 Koc,
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? SUN of someone other than spouse,
ini flri(9whom:
Kies [ No
- If name-ori record is different than that of applicant,indicate below: - —. - -- ' -- — •- -
GPt3GN CO"C
UN�A�01��p
ri
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 ko EYes ❑ 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?
KYes [ No ❑Yes o
Taxing district Key number/Legal description Record number*(contract) Page number( nt ct)
v
00
1011A-1- 10 4 —Ooo.3S o o l-
INVe certify under penalty of perjury that the above and foregoing information:is true and correct. c ....\
Signature of applicant • Address of applicant (number and street,city,state,and ZIP code)
r i .), di Kix-IL, 341 '
S' .it 01dfd )a d '� (0Et)eGSignature of authorized representative Address of authorized representate (number and street,city,state,,an -
I '
•USAF Social Security Administration
6,fJ IHJU� ,? Benefit Verification Letter G
�Ilr� wiIVIhIIhII1uI�rl�nii�gii�l�ii�i �unlu��ldhlli o
RONDA LEE KOCH
gmel
331 VINE ST ,
OAKLAND CITY IN 47660-1247 O 0
You are entitled to monthly disability benefits.
Qnet AT.,. + Pour"
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