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4:--=' APPLICATION FOR BLIND OR DISABLED PERSON'SictI COUNTY TOWNSHIP YEAR
• Y \ DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R14/9-24) 0
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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
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Name of Applicant(owner or contract buyer)
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Is applicant the sole legal or equitable owner? If No, what is his/her exact share or interest? If owned with someone other than spouse, indicate with whom
101‘ ❑ No
If name on record is different than that of applicant, indicate below:
Name of Contract Seller
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Address of Contract Seller(number and street, city, state, and ZIP code) Is the Property in Question:
eal 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 D#.1 es ❑ 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?
es ❑ No ❑ Yes 1;i1Co
Taxing District Key Number/ Legal Description . Record Number(contract) Page Number(contract)
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of plicant Address of Applicant (number and street, city, state, and ZIP code)
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Signature of Authori d Representative Address of Authorized Representative (number and street, city, state, and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Name of Applicant Date Filed (month, day ear
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Name of Contract Seller
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Taxing District
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Key Number I Legal Description Azesiza41 a. rai-irn i)
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GIBBON COUNTY AUDITOR
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Signature of County Auditor p ^� Date Signed (month, day, year)