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04 ,40„ APPLICATION FOR CREDIT AGAINST PROPERTY
• .� .� COUNTY TOWNSHIP YEAR
41;;1 .1 _' TAXES FOR BLIND OR DISABLED PERSON
State Form 43110(R1517-25)ski e,
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0?0\r\ FiCA 11 )01 2,- )
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,la� ,r% Prescribed by the Department of Local Government Finance .
Instructions: To be riled in person or by mail with the county auditor of the county where the property is located. 00
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.
Name of Applicant (owner or contract buyer)
with Som than Spouse, Indicate with Whom
es 0 No
If Name on Record is Diff re I than that of Applicant, Indicate Below:
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Name ofContract Seller Address of Contract Seler(number and street, city, state,and ZIP :) 2026
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Is the Property in 0 scion: Is Applicant Blind (as defined in IC9#,e.
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eal Property Mobile Home (IC 6•1.1-7) Yee Ib \Jo
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Is Applicant isable and Unable to Engage in Any Substantial Gainful Activity? Is the PropertyUsed and Occupied Primarilyfir His/Her Residdnce?
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Yes p No ties [iNo
Taxing District — Key Number i Legal Description Record Number(►antra• ) Page Number(contract)
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— 000 , "91-3.--00 '---
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature f 1 Appli Address of Applicant (number and street, city, state, and ZIP code) C
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ignature of Authorized Representative Address of Authorized Representative(nu)nber and street, city, state, and ZIP code)
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any of this information,
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