HomeMy WebLinkAboutDisabilty_Lewis"" " APPLICATION FOR BLIND OR DISABLED PERSON'S
r! � DEDUCTION FROM ASSESSED VALUATION
State Form a3710 (R / 9-96)
���d e Prescnbed by the State Boardbf Tax Commissioners
rmation contained in ihis document is CONFIDENTIAL pursuant to IC 72-7-1-1(n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING:
To be filed in person o; by mail with the County Auditor ol the county where the property is loca-
ted during the 72 months before May 17 of the year the deduction is to be eNective. � E� 1 j 20�0
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Name of applicant (owne� or contract buyer) , ry!
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GIBSON UNTY AUDIiCR
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Is applicant the sole legal or equitable owner. o;-whatis'hisfier exact share of interest? If owned with someone other than spouse. �
indicate vrith whom
s ❑ No
If name on record is different th that of applicant, indicate below
Name of contract seller � -
Address of con[raci seller ,
Is applicant blind as defined in IC 72-1-7-1(n) and IC 6-1.1-72-72(b)? Is applirant disabled and unable to engage in�%�'� bstantial gainful activiry
,.�"� as defined in IC 6-1.1-12(d)? flkv65 ❑ No
O Yes �x+yo Sy
Is the property used and occupied primarily for hisiher residence? Does the applicani's taxable gross income tor the preceding calendar year
� exceed 577,000?
❑ No ❑ Yes
Ta�cing district Key numberlLe9al description Record number Page number
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I/VJe certify under penalty ot perjury that lhe above and foregoing information is true and correct and that lhe applicant was a resi-
dent of Indiana and owner of the aforementioned propeRy on March 1, 19 _.
Signature of applicant Si9nature of authorized representative (by executed Power olAttomey)
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Ad ess ot applicant Adtlress ot authorized representative
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