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e:-.111*\., APPLICATION FOR BLIND OR DISABLED PERSON'S
' ,, COUNTY C . 1_ TOWNSHIP YEAR
�; = DEDUCTION FROM ASSESSED VALUATION
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State Form 43710 (R14/9-24)
�� Prescribed bythe Department
apart ant of Local Government Finance �1'� 1 D11.
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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
Name of Applicant(owner or contract buyer)
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
es ❑ No
If name on record is different than that of applicant, indicate below:
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Name of Contract Seller
Address of Contract Seller(number and street, city, state, and ZIP code) Is the Property in Question:
eal Property Li 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 r' o es G 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?
11-1 0 No ❑ Yes
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.
Signatur of Applican 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)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Name of Applicant Date Filed (mont Iiir'►, ar
ED
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Name of Contract Seller
DEC 09 2025
Taxing District
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Key Number/Legal Description GIBSON COUNTY AUDITOR
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Signature of County Auditor Date Signed (month. day, year)
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• = '= Social Security Administration
, Benefit Verification Letter cp
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JEROME LESLIE WILZBACHER
01
1101 E STATE ROAD 168
FORT BRANCH IN 47648-8037
You are entitled to monthly disability benefits.
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