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,,�`'�"n APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEp.�t
i:�� DEDUCTION FROM ASSESSED VALUATION
'•:..�( State Fortn d37 f 0(R7 I SO6)
Presaitx,d by Ihe Department W Loral Governmrnt Finance
nf,�ation contained in ffiis dowmen� is CONFIDENTIAL pursuaN to IC 12-7-1-t(n) and IC 6-7.7-12-72(b�. �
INSTRUCTlONS:
To be liled in person or by mail with the County Auditor o/1he county where the p�operty is focafed. 7 Z��a
Filing Dates: i) Real Property Dunng fhe 72 months betore June 71 of the year the deduction is to be��ti�.
2) Mobile Homes assessed under IC 6-1. 7-7: During the 12 months belore March 2 ot each yearlhe individual wishes to
obtain the deduction. � ��
See reverse side (or addrtional instrucfions d ualifications.
INam ol appli R(owner or contract buyerJ ��
�/� GIBSON COUNTY
�f
Ls applicant the so e legal or equitaWe owner? If No, what is his/her �
❑ Yes O No
If name on rewrd is diRerent than Nat of aod�cant, indicate below
vnth someone other than spouse,
wiih whorn
Is Ihe property in queSGon:
ea1 Property ❑ MotMle Home (IC 6-1.7-7)
applicant blind as defined in IC 12-1-1-1(n) an0 IC 6-1.1-72-72(b)? Is applicaN disabled and u le to engage in any substantlal gainfW acfiviry
�,J as definedinlC 6-1.1-12-11(d)?
❑ Yes LXNO s ❑ No
the property used and occupied primarily (or his/her residence? Dces the appliwnt's taxable gross income (or e preceding calendar year
exceed $17,000?
s ❑ No ❑ Yes ❑ No
�ting�disRict � � Key number / Legal dewiptlon Record number Paae numher
-(�c��{S � � ��-00 O• °�" p� /^7
IM/e certify`Gader penalty of perjnry that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
IignaNre o1 applicaN SignaNre of authorized representative
.�„� � !l /% i/7 ' � _ V .
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