HomeMy WebLinkAboutDisabilty_Cornoyer -4 • APPLICATION FOR CREDIT AGAINST PROPERTY
tr ' -- �� TAXES FOR BLIND OR DISABLED PERSON COUNTY TOWNSHIP YEAR
State Form 43710 (R15/ 7-25)
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-%.4_,� Prescribed by the Department of Local Government Finance
Instructions: To be filed in person or by mail with the county auditor of the county where the property is locat4 I; I / (i i,. ,
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.
Owned with Someone Other than Spouse, Indicate with Whom
'Yes ❑ No
If Name on Record is Different than that of Applicant, Indicate Below:
Name of Contract Seller ' Address of Contract Seller(number and street, city, state, and ZIP code)
Is the Property in Question: Is Applicant Blind (as defined in IC 12-7-2-21(1))?
Real Property ❑ Mobile Home (IC 6-1.1-7) ['Yes -No
Is Applicant Disabled and Unable to Engage in Any Substantial Gainful Activity? Is the Property Used and Occupied Primarily for His/Her Residence?
14 Yes CI No t'es ❑ No
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istrict 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 App .nt Robe B GI Address of Applicant (number and street, city, state, and ZIP code)
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Signatu e . •uthonze -presentative Address of Authorized Representative (number and street, city, state, and ZIP code)
RECEIPT FOR APPLICATION FOR CREDIT FOR BLIND I DISABLED PERSONS
Name of pplicant Date Filed (month, day, year)
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Name of Contract Seller
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Taxing ict
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Key Number/ Legal Description
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Signature of County Auditor // Date Signed (month, d )
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Notice of Award
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ROBERT B CORNOYER
274 W 225 N
PRINCETON, IN 47670-8533
You are entitled to monthly disability benefits beginning September 2013.
What We Will Pay And When
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