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• "" APPLICATION FOR BLIND OR DISABLED PERSON'S courrrr TOWNSHIP r�e
r. -- - DEDUCTION FROM ASSESSED VALUATION
, - � S�aOa Fam 63710 (R9 / 9-08)
Presaibed Cy Ne Oepartmem d Lolal Governmen� Financa
�fwmatam m�tained in this doament is CONFIDENTIAL pursuan[ to IC 6-1.1-12-12(b). FI M
fNSTRUCTIONS:
� To be filed in person w by mail wdfh the CamtyAudita ol the oow�ty ri+eie the property is bcafed.
Fa;� oa�a:: �� aaei P,o�,ry o�,;.g rna Yaa. ro. wna, Na eae„�sa, ;� �nc D E � 1 2 2011
z� ti+oaae Ho�res a�re�o ��aer ic e-�. ia of n+a��tacn,red H«rres �wr es��d � Reai a�erty ow��y ma n�a (n) r�ms aerae
March 31 d earh year the irMividual wishes fo obfain the deduction. C.�, �...�
See reverse sMe Ia ad
Nartre o( aPV��M (�+�
Is applimN iha sda legal or eQuitabla wrtieR
fwne m
i�',!1
ndd.� w ��aa
aretl
H No, what is hisTher ezaG share d irrtarest7
IAIYes U No �
7"
jreM ihan Cwt d app&ant ��+�te Cab.^
�
x(m�mDer antl s4ee4 �: stala. aM ZIP wda)
GIBSON COUNTY AU
tl owned with somep�e tltrer ihan spouse,
'vdimte wilh wfpm:
Is Ne properry in Question
❑ Re��rop�+v 0 /v,r�anv/�sessed
Mo6ae tiort,e (�C s-t1-�
k app6raN diM az debned in IC 72-7-2-21(1 �? Is appl�nl tlisableA aM unaMe lo ergage in arry su05taNial gai�ul arfivity
as defined in IC Gt 1-12-11(d)?
❑ Yes No es ❑ No
Is Ne AWaM uSeA anC ottupiad WinunA (ot hNtrer resdexe? Does �he aV7�M's tasade gmss incoma br Ne G���B mleMar year
azoeeG 517.0007 '
� Yes ❑ No ❑ Yes ❑ No
Tazing dislrid Kay number I Legal desaiptbn Record number Page number
��vw�Q a�-�3-afl-lol-a-�a I
VWe certify under penalty of perjury that lhe above and (oregofng information is true and correcl and that fhe applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
aearess of apoham pa�,ber a�d sneet dry, ��. a„e z�a mae�
7 /�' �i/n � S �" f/s
AEAressolaulhorizadrapesanlativa (numGrsandshccl,ciry,slafo.andLPcade)
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