Disabilty_Field��"� APPLICATION FOR BLIN DISABL RSON'S
� ��'s, DEDUCTION FROM ASSES ION
;,�` State Form 43710 (R715-O6)
Resai6ed by tlre Deparlm�i W Locil Govunment Finance
�Infortnation contained in this document is CONFIDENTIAL pursuant to IC 72-7-7-1(n) and IC 6-L1-72-72(b�.
NSTRUCTIONS:
To be filed in person or by mail with the Counfy Auditor of the coun(y where the property is locai...,.
Filing Dafes: 7J Real PropeRy: During the 72 months 6efore June 17 o7fhe year the deducfion is to be effective�EP 7 �7
2J Mobile Homes assessed under IC 6-1. t-7: During the 12 months 6e(ore March 2 o/each year the indlvi�uA74�es to
o6tain the deduction
See reverse side for addrtional insfrucfions and ualificafions. a4 �� _
Name of appl/iw1nt (o1w,.n,er or contract buye �.
\ l' I� /1 X V X 1 � ����' ��U-�lC '`. 1 1 n� n 1/ �� GIBSON COUN7Y aUDiTOR
appllwnt Ihe sole legal or equitaNe owner?
❑ Yes O No
name on record is diRerent than that of applican
ame of contra seller
�_�
Address of convac� seller
6 appliWnt blind as define
Is �he property used and o
� No, what is hisRier exac2 sh
indica�e below
it ovmed with someone other than spouse,
indicate with whom
Is the property in question:
❑ Real Property ❑ Mot�le Home QC G1.1-7)
in IC 12-7-1-1(n) and IC 6-1.7-72-12(6)? Is appliWnt disabled and unable to engage in any subs�antial gainful activiry
as defined in IC 6-t7-12-N(d)?
❑ Yes o s ❑ No
upied primarily for his/her residence? Does 1he applicanPS taxable gross income for fhe preceding wlendar year
exceed 517,000?
s ❑ No O Yes ❑ No
Key number / Legal descripUon Rewrd number Page number
�o-�� a f�-l� �-�frz6--G�b.1/ -DO5
I/We certify under penalty of perjury that the above and foregoing information is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
S'ign/�ature
r f�
applicant / . �-/763PIAddressof
representative