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-,�i' A4 APPL9CATION FOR BUND OR DISABLEO PERSON'S
'. ; AEDUCTION FROM ASSESSED VALUATION
� Sia�e Fam d3710 (R7 / 5-06)
� Presai6ed h Ihe De
Y p-ulmaii d Local Govunmeni Finance
COUNTY TOWNSHIP YEAR
� �
��n;ormation contained in this documenl is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC b-7.7-72-72(b). File Mark
NSTRUCTIONS: SEP I 4 Z00%
To be tiled in person o� by mail with the County Audifor o7 the county where the propeRy is locafed.
Filing Da(es: 7) Real Property: During the 12 months befo�e June 7 7 07 fhe yea� the deduction is to 6e eflgpqqe.
2J Mobile Homes assessed under IC 6-1.7-7: During the 12 mon[hs 6efore March 2 oleac�year in�al wishes to
obtain the deduction. GIBSON COUNTY AUflITOR
See reverse side tor additional instructions and uali�caGons.
Name ot appliwnt (owner or conVacf buyerJ ^
(.c%�G��,, � 9� �-fiz'L Q/ �4 �-
nameon
o,
❑ Yes ❑ No
is diflerent than that of apWiwn
ame of conVact seller
idress of wnVact seller
appliwnt blind as defined in IC 12-1-1-7(n)
❑ Yes �
the property used and occupied primaril o
❑ Yes ❑
odng district . ,
!.T�-1RR7
and IC 6-1.1-12-72@)?
No
exact
with someone other than spouse,
wi�h whom
Is the property in question:
� �Real Property ❑ RAobAe Home (IC &1.1-7)
I disabled and unable to ergage in any substantial gainful activiry
in IC 6-1.1-t2-71(d)?
the applicant's taxable gross
d $17,000?
.1 I �
� Rnrnr
❑ Yes ❑ No
(or fhe preceding calendar year
IMle certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
of applirani
�
Signature of
aVV������ � . • Aatlress of authonzetl representative
'i�o7% � %80 S �r-fB�nr�