Disabilty_Deckards
°"° APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSXIP
,. � DEDUCTION FROM ASSESSED VALUATION
State Fortn a3710 (R / 9-96)
�,� � PresviDeA by Ne SWte Board ol Taz Commissioners
Ir�tion contained in this document is CONFIDENTIAL pursuan� to IC 12-1-1-1(n) and IC 6-1.1-12-12(b)� �
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor o/ the county where the property is loca- SEP 2 3 �997
ted during the 12 months be%re May 11 0! the year the deduction is to be eNective.
See reverse side for additional inshuctions and quali/ications. _ n . _ ,
is apaican� trye soie �egai or
V
If name on record is ditteren�
Name of conVact seller
Address ot contract seller
Is applicant blind as defined
Is the property used and oa
�
� 'i'
No, what is his�her exact share of ir
Cd�Yes ❑ No �
than that of applicant, indicate below
in IC 72-7-7-7(n) and IC 6-1.1-12-12(b)?
❑ Yes ❑ No
❑ No
as
ezceed $7
GIBSON
r�,a
If ownetl with someone other than spouse,
irMicate with whom
t disabiea and unabie to engage in an bstanUal gainful activi�
in IC E7.7-72(d)? es ❑ No
pplicanYS tazable gross income for the preceding calend�f year
❑ Yes L�7
number Page
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned pro erty on March 1, 19
� tur of� � � Signature ot authorized representative (by executed Powei olAttomeY)
.
Address of authorized representative
�
�