Disabilty_Coker°"' APPLICATION FOR BLIND OR DISABLED PERSON'S courun TOWNSMIP r�uc
: DEDUCTION FROM ASSESSED VALUATION
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Sbb Form 43710 (R919-08j
� PrewibeC by Ne Deparlmen� d Lod Grnertvrrenl Firunca
�formatbn conlained in fhis document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). N O V F�e IAa�iho�7
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INSTRUCTIONS:
To be filed in person w by mai! with the CountyAUdrlor ol fhe oow�ty where the poperly is bcafed.
Fdirg Dates: 7) Real Property: Dunrg the yeai for which Ne ded�sctbn is soughL `Q—}'����'� �
2) Abbile Homes assessetl uMer IC fi-7.1-7 or ManNactured Homes not assessed as Real Property.� Ounrg ih(jwe7ve ( g�p� be/ae
March 3t dearh yearme indivitlua�wishes ro obtain the deductian. GIBSON COUNTY A DI IOrs
See reverse sde /a adddional insWdions and p�aliRwtians
Nama appliranl (owir� or cmtracl dryoQ
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Is applimnt Ihe sde ieqal w eQUea61e rnvnaR H N is hisTher ezaa shara of interestl tl owned with sorteme olher Itwi apwsa.
'vdimte wilh whom:
❑ Yes ❑ No
H rame on recard'a?dferent Ihan that of appfirant iMxata belar.
Name dmntrad se0ar
Pddress d mntrae sa0er (ramDer and sbut4. U�: sb4. antl ZIP o000) !c I�e properry m Questim
❑ ReaIR'opeAV ❑ nrvwa9rnssessea
'- Mohde Hortie (IC G7.1-7)
Ls applimm b6n0 az tlefineE in IC 72-7-2-21(1r Is applimnt disa0leG anC unable lo ergage in a�ry subslaNial gairi(ul aCivity
as defined in IC 61.142-N(d)?
❑ Yes ❑ No Yes ❑ No �
ls �he V�M used a�W occuPed A��^T/ br �islher rasdence? Does Ihe aPP��nfs �axade grass irwma for Iha G�aceding caleMar y�r
,�y eimeG f 17.0007
,t9 Yes ❑ No ❑ Yes ❑ No
(az'ug dislrid Key number I Legal desaipimn Remd num�er Paga number
�.� � ��'-/-� �-�8-13 -/o�-00%//5-oa6
IIWe certify under penalty of perjury that lhe above and foregoing infortnation is tnie and correct and thal the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Sign of appfiranl dress ot appli�M (inmberaiW sbeet, py, state. aM ZIP mtle)
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Signature da � ed repr tative Adtlress ot ulhw"ved semative (nwnJ�raM slreel, city, stam, LPwde)