Disabilty_Dillard�
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�� � APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
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�` ' State Fortn 43710 (R7 ! 5-06)
Prewibed by Ihe Department of Locil Govemment Fin.v�ce
COUNTY I TOWNSHIP I YEAR
�In(ormation con[ained in this documeN is CONFIDENT�AL pursuant to IC 72-7-7-1(n) and IC 6-7.1-12-'f'L(b�. Y�� �� ��a�
NSTRUCTIONS: � �,PR O % ZOO9 /
To be �led in person or by mail with the County Auditor o/ Ihe county where (he propeRy is locafe
Filing Dales: i) Reai Property: During the 72 months before June 7 7 of the year the deduclion is fo be eNective.
2) Mobile Homes assessed under IC 6-L 7J: During the 72 months 6efore Ma�ch 2`b�g�ash ye�ar�individual �vishes to
obtain fhe deduction. � �`�
See reverse side for additional instruc6ons and ualitcalions. �iBSON COUNTY AUBlfiph
Name of applicant (owner or conVad buyer)
Is appliwnt Ne wle legal
If name on record is difter
Name of contraG seller
Address of contract seller
Is applicant biind as defin�
Is ihe property used and c
or eqwtaWe owner? If No, what is
❑ Yes O No
=_nt Nan that of appFcant, indicate below
I with 5omeone olher Ulan 5pouse,
V/IUI W�IOIf1
Is Ihe property in questlon:
L4 Real Properly ❑ MobOe Home (IC 6-1.1-7)
1-1-1(n) and IC 6-1.1-12-72(b)? Is applicant disabled and unable to engage in any substantial gaintul aGiviry
as defined in IC 6-1.1-12-71(d)?
❑ Yes
❑ No
number / Legal descriptlon
-1 a -30 I -ct�3. o8" 5
�11'es ❑No•
gross income for the preceding calendar year
❑Yes �
ReCOfd number Paae numher
I/We certify under penalty of perjury that ihe above and foregoing information is true and correct and that the applicant was a resident
of Indiana a�d owner of the aforementioned property on March 1, 20 _
SignaNre of appliwnt
�`!c' �.�Q
Add�of appGCant
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