HomeMy WebLinkAboutDisabilty_Prickett��' a� APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VAI.UATION
State Fortn <3770 {R7I S�U6)
.. �
Prescribed by Ihe Dep.xnnrnt d LocM Governmrnt Finance
COUNTY TOWNSHIP YEAR
�nfamation conlained in this document is CONFIDENTIAL pursuant to IC 72-1-1-7(n) and IC 6-1.1-72-12(b� �� �J�e afk
i
NSTRUC7IONS: Jj J
To be liled in person o� 6y mail with the County Auditor ol the county where fhe property is located.
Filing Dates: 7) Real Property: During the 12 months 6efore June 17 o7the year the deductfon is to ba�c�ivQ �Qnp
2) Mobile Homes assessed under IC 6-1. 7-7: During the 12 months before March 2 of eac yeaYth iNbividual wishes lo
obtain the deduction. � �
See reverse srde for additional instructions and ualifications.
�me o( a icant (ownerorconb � b er) GIBSON COUNTY Alinirna �
.w .
�� appliwnJ►he sole legal or
U
name on record is difteren
ame of co�VaC seller
ddress of conVact seller
owner? �I(
❑ No I
applicant, indicate below
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-72-12(I
❑ Yes No
Is the property used and occupied prim � for his/her residence?
es ❑ No
axing diSVict Key number I
1i/!A .J��. ri�%]L �
exaG share of interest? If owned vrith wmeone other than spouse,
indicate vriih whom
Is the property in quesGon:
❑ Real Property ❑ Mobile Home pC 6-1.
Is applicant disabled and unable to engage in any sub ntial gainful aclivi��
, as de5ned in IC 6-'1.1-12-11(d)?
es ❑ No
Does the applicanPs taxable gross income (or the preceding cale ar year
exceed 577,000?
❑Yes No
aae number
I/We certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
representative
applirant ' �Address of authorized
� �