Disabilty_Utley"'" APPLICATION FOR BLIND OR DISABLED PERSON'S
. - DEDUCTION FROM ASSESSED VALUATION
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Slafe Fortn 43710 (R9 / 9-OB)
P�asaibed by Me Dapanment d Loml Ga.remment Fnance
Informatiom m�taineA in this tlowment is CONFIDENTIAL pursuant lo IC 6-1.7-12-12(b).
COUNTY TOWNSHIP YEAR
Ile
INSTRUCTIONS:
To be �7ed in person w by mal wifh the Co�wAyAuditcr ol fhe awnry wfiere fhe properfy is bcaled.
Fa;�y oare:: �� aea� a.oPeny: o��,g r�a yaa. r� wner, me aea�no� r5 ��nt. .l U L 2 5 2011
2) Mobile liomes assessed under �c 61.1 a or Manu�actured rfomes na assesced as Rea� Properry: ounny the nve�ve /1z) monfhs be/ore
Maich 31 d each yea� Me iMividual wishes fo obtain the deductiwi. C. �. �
reverse side far aOddional insWdions and 4ualifications. �
N""eua°a°`°�""e`«`°''o-�r°"y�'� GIBSON COUNTY AUDITOR
k ecoticam u» sda ieg
C riame on mcard is dA
Name o( w�irar� seGer
H No,
U Yes u Na �
ttun Cut oF app�ranl inA'xate below:
AEEr855 of mnt�ad SeOer (mmNev aM SEee4 cNY. 5fdfe. ad LP oDdo)
az
❑ Yes ❑ No
Is ihe p�opeM � and ocaped prinwriry br hislher rasdence?
❑ Yes ❑ No
axap share ot imereslT
i �ey� aa:a�w�
�
tl wrtied wGh someone altrer Uun sGa+se.
intliole wilh wtqm:
Is Ne m que5tim:
�Y � n�o�iiome (� t.ta)
la to e�gage "vi arty v�bstantial gajp7ul aCivity
�Pes U No
Daes the apd�nTs la+able gross incane br tM preceCing nlendar year
ezmetl f17.000? .
❑ Yes No
IIVJe certify under penalty�of perjury thal the above and foregoing information is true and correcl and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
o� a�ik-am (�nonbw and saeeC ary. sfam, aiW Z/P
of authorired 2preaentative
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streef. city, slale. antl LP cotic)
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