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Disabilty_Jenkins
,Reset Form P APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR t�l -_r1 DEDUCTION FROM ASSESSED VALUATION i - State Form 43710 R 1419-24 j iii)- \( . /C' 4 Z,C Ili Prescribed by the Department of Local Government Finance - 401 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 buyer) j/1 1 tkb —D (j' —' krk-i Kr s applican the sole legal or equitable owner? If No, what is his/her exact share or interest? If owned wi om e her th au irate with whom t, ""%si es o ame on record different the of applicant, indicate below: SEp 1 n , r/SifiRLEyjJfiAJ / 2202 Name of Contract Seller crQsoN C � OUNT Address of Contract Seller(number and street, city, state, and ZIP code) Is the Property in Question: I7.0p 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 ac>ivity as defined in IC 6-1.1-12-11(d)? Yes XNo ' (Yes 0 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 517,000? Yes ❑ No © Yes No Ta ' District Key Number I Legal Description Record Number(contract) Page Number(contract) (1k/\167e7/)&. bA3 0Z-a ''46 ‘;164.4- 1 O a,37q-c; IIWe certify under penalty of perjury th t the above and foregoing information is true and correct. Signet • i f Applicant Address of Applicant (number and street, city, state ZIP cod - td11/ /// _ l'/ C:1- Sr.4717 r RI ki A) , )Al 47 ?D „i 1 ignature of Authorized Represen ive Address of Authorized Representative (number and street, city, state, and ZIP code) Notice of Award 0 d IiIIiniJIIIJil*IiUulIiIIIIiIIIiliiIiJliIiiIliiiIilIiliiIiIiIIii N 0000412 00016369 3 MB 0.439 0219M3MCS5PI T119 P13 0 sttri MICHAEL D JENKINS 604 E STATE ST PRINCETON, IN 47670-1910 You are entitled to monthly disability benefits beginning.November 2019. C See Next Page