HomeMy WebLinkAboutDisabilty_Tabb� ° APPLICATION FOR BLIN R DISABLED PE ON'S
; — DEDUCTION FROM ASSE LUAT
� Slale Fam a3710 (R919-08)
, r
Prewibed Oy Ne Depanmerq d LoW Go�eenmenl Firiance
�nformatbm m�tainetl in Vris tlopiment is CONFlDENTIAL pursuaN to IC 6-1.1-12-72(b).
COUNTY TOWNSHIP YEAR
Rle Mark
wsrRUCnoNS: SEP 2 9 ZU10
To be filed in person or by mail �ith the Coix�tyAud"Aw o7the wunty where the poperty is locafed.
Fdirg Dates: if Real Pioperty: D1airg the year Icr whidi Ure tleduction is so�ght
2 Mobile Harres assessed undei 1C S7. 7-7 or Manu/actured Hortres irof assessed as Real �
) Roperty Dun (��Ms 6efae
Mamh 37 W each year tlre iiMividual wishes to obfain fhe deduction.
Seereversesitlefaa0ditronalinstnidionsantlqualifications. GI6SON COUPlTY AUOITOR
Name d�{�pkam (owriv ar cantfact�ry�
H No, what "s hislhx ezad shara o( iNaresR
❑Yes ❑No I
H name m recad is d'Afarent Nan that of appfrant iMicale beb�r.
Nartre o( mnlraGlSe�ar
Addrass of mntraC saGer (manDOraE sbuof. rify: sfab. aM ZIP mEe)
Ls appfimN 6GM ss CeEneE in IC 12-7-2-27(11?
❑ Yes
Ls c�e P�waM usea and ocwdad P���Y
❑ No
d'a1+id
Key number I Legal desaip�ion
H owned wiU wmearie olher Ihan sGWSe.
'vdimle wdh who�rc
LS pfp�lBf1)'IfIG11B511(NC
�RealROperly � MnuaOyAssessed
MobBe Flmie (IC 61.1-7)
Is applicaN disableE aM unabla lo etqage in arry wbstaNtal gairdul adivRy
as Eefined in IC 61.1.1Z71(d)?
❑ Yes ❑ No
Does IhB aVP���'s laude grass "uKana (w the Wated"m9 ralandar year
e�weE 417.000?
❑ Yes ❑ No
Recrntl number Page numDar
IIWe certify under penalty of perjury lhat lhe above and foregoing infoimation is W e and conect and that the applicanl was a resident
of Indiana and owner of the aforementioned properly on March 7, 20 _
rapresen�a4ve
/ddmss o� applitan� (nvn0araiM sGeef. cily, sfa2, an0 ZIP cotle)
�?J G� s. C4 H.bc,-��p% 5/; -�� �r✓r..c{��
Mdress of authorizeE reoresanlatrve (nivnbr aM stmef, c:ry. slafe, antl LPCOde) �7 6yB