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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Stab Farm 43710 (R9 / 9-08)
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�forrtia[am m�tained in this Aoaiment is CONFIDENTIAL pursuant to IC b1.7-12-12(b).
lNSTRUCTIONS:
COUNTY TOWNSHIP YEAR
file Mark
To be filed in person or 6y mail Mith the CantyAutlrla of lhe county where Me poperiy is bcated. �����
Filug Da�s: i) Real PropeAy.' Dunrg Ne year for whirh the deductim is swght.
2) Mobile Homes assesSeG under IC 61.7-7 w Manulactured Homes nW assessed as Real Property Dunpyt� (welve f7�� monfhs 6e/de
Marrh 31 deech year p�e individual wishes to abfain Ne deduction. Ml�� � [
See reverse sde 7or adddional insWcfions aM qualificafions
Name d aPPfi��� (m.rwl n ronhart�'��� .
� � GIBSON COUNTY AUDITOR
Ls aaW�m the sde tega� or ea��ade ameR tt No, wna� is t�smer e,ad m meresn wmee wan someme aher inar� scwse,
icate with whom
Yes ❑ No
It name on recoN L5 CiHarenllhan Mal d appfifant intli�sle babw.
Name seder V\--- /`=�>�
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Addrass d wntratl sa0er (rvmi6er an0 stroeC � b. and LP mde) Is Ne P��M �^ N+estion:
❑ R��v ❑ e��nvn��a
nnobae Horne pc ��.�a)
Is app6mN bFnd as Ee6ned in IC 12-7-2-21(1 n Is applimfn disaDleE and unabla ta e�gage in ary s��tantel gairdul atiiviry
as Aefined in IC 61.1-12-N1d)?
es ❑ No [!�� ❑ No
Ls cie P�PaM used and ocwpied P�^��N Iw �i4her raside�ce? Does Na avP�m's lasable gmss income br Ihe P�eceCing nleMar yaar
az�e0 517.000?
es ❑ No es ❑ No
�in -tricf Keynumber/Legaldesaip�ion Rervrtlnumber Pagenumbar
C��d-D(o -�fQ3- �C�05'-0 3.�
IIWe certify under penalty of peryury thaf the above and foregoing information is true and correct and that the applicanl was a resident
of Indiana and owner o( lhe aforementioned property on March 1, 20 _
Signaturedapp(vM PdEressolapplimM (nanD�raMshcef,ory,state,a�tlZlPwtle)
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Sgnalure W a eA rapresentativ AGdress ot aulhoraed reprasenta�ive (numJeraM sbeet, riry, gafe, and LPade)