Disabilty_Land°""° APPLICATION FOR BLIND OR DISABLED PERSON'S cour+rr TOWNSHIP reaR
: - . ; � •vEDUCTION FROM ASSESSED VALUATION
S ; Siate Fortn 43770 (R6 / 4-04)
__ Prescribed by Ne Department of Loral Govemmeni Finance
7
I�UCTIONSed in this document is CONFIDENTIAL pursuant to IC �2-1-1-1(n) and IC 6-1.�-72-1 . ��jj �Fi M
�LJ
To be filed in person or by mail with the CountyAuditor o/ the county where the property is located
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to�tie,effa�ti�.2��7
2) Mobile Homes assessed under lC 6-1.1-7: During the 12 months befo�e March 2 of each year the individual wishes to
w�mu me uewcuvu. - �F� � ,
See reverse side for additional instructions and ualifica6ons.
Nameofappliwnt(ownerorconfrectbuye) • GIBSONCOUNTYAUDITOR
�rm� O �' o`��. `o�c�,0
Is applirant the sole legal or equitable owner? if No, what is hislher exact share of interest? If ovmed with someone other Nan spouse,
indicate with whom
es ❑ No
If name on record is diRerent than that of applicant, indicate below
Name of conVad seller
" \..
Address of conVact seller Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-7)
Is applicant blind as defined in IC 12-�-1-1(n) and IC 6-1.1-12-�2(b)? Is applicant disabled and unable to engage in any substantial gainful acGvity
as defined in IC G�.1-12-77(d)?
❑ Yes o es O No
Is the property used and ocwpied primarily for his/her residence? Does the applicanYS faxable gross income fo e preceding calendar year
� exceed 517,000? �
Yes ❑ No ❑ Yes ❑ No
Taxing disirict - Key number / Legal description Record number Page number
���3��-� ae-I�-is-ioi-cbi.���
I/We ceAi(y under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature of applicant Signature of authorized representative
�. ��
Add` s^s of appliwnt Address o( auihorized representative
/`-'