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.c�`= fir% APPLICATION FOR BLIND OR DISABLED PERSON'S r COUNTY TOWNSHIP YEAR
ill i .. DEDUCTION FROM ASSESSED VALUATION
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*\. / State Form 43710(R1410-24)
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Prescribed by the Department of Local Government Finance -
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 0(\r\M-e_4-- \)\ ‘\
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 propert - first due and payable.
See reverse side for additional instructions and qualifications.
Name of Appf nt (owner or contract buyer)
47.
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Is applicant the sole legal or equitable owner? If No, what is his/her exact share or interest? If owe with someone other than spouse, indicate with whom
X(es _ No
If name on record is different than that of applicant. indicate below: 1112&ithila. iii(1114.144)
casoN GouNTY AUDITOR
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 r any substantial gainful activity as defined in IC 6-1.1-12.11(d)?
J Yes X:'Jo Yes r-. 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?
XYes i No 0 Yes E No
Taxing District()
Key Number I Legal Description Record Number(contract) Page Number (contract)
06,5D 1 eI�/ 111`(Je - '/`f�/'f --rJ�/J�I1 40 000/ �•//�J' (//(��f VI6 ,2V arr _ , a6
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of Applicant Address of Applicant umber and street, city, state, and ZIP code 0lI kL J- 2-f
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Sig r e of Authorized Representative Address of Authorized Representative (number and street, city, state, and ZIP code)
Azel Wayne Willis, Sr.
5048 S Washington St
Oakland City, IN 47660 •
Notice of Decision — Fully Favorable