Disabilty_Dant . ...0. ► Reset Form
‘50-'74. , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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`.. DEDUCTION FROM ASSESSED Ig ,, , , VALUATION
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. ` v.�v State Form 43710 (R141424) Cy V) 02g c
'•,r 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
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Name of Applicant(owr or contract buyer)
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Is nt the sole legal or equitable owner? If No, what is his/her exact share or interest? If o ne h meon: 2 r t • use, indicate with whom
Yes J No
If name on is different than that of applicant, indicate below:
DEC 01 2025
Name of Contract Seller
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Address of Contract Seller(number and street, city, state, and ZIP code) Is the Prti ;ONNTY AUDITOR
Real Properly ❑ 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 unai •• to . e .• in any substantial gainful activity as defined in IC 6-1.1.12-11(
U Yes No Yes •ii
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar ye r ex eed $17,000
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Taxing District ey Number 1 Legal Description Record Number(contract) Page Number (contra t)
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
ignature o Applicant cb -
l\ DX r Address of Applicant (number and street, city, state, and ZIP code)
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Signature of Authorized Representative Address of Authorized Representative(number and street, city, state, and ZIP code)
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'�f NI/ �Z Benefit Verification Letter W
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N,s,',ST-it Date: December 1, 2025
BNC#: 25JA236K81741
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DARRIN THOMAS DANT vo
727 S PRINCE ST CT
PRINCETON IN 47670-2623 , DEC 0 2025 0
You are entitled to monthly disability benefits. a'es e
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