Disabilty_Blythe�'°'"o APPLICATION FOR BLIND.OR DISABLED PERSON'S couNrv TOWNSHIP vEnR
� DEDUCTION FROM ASSESSED VALUATION �-� ., I
i!.-"-.. . . . ... , � .
� ' �State Fortn a3770 (R4 / 70-01)
S:�: "� Prescnbed by ihe DeDanment of Local Govemmeni Finance � ,
�I-`-�rnation contained in Nis dowment is CONF�DENTIAL pursuant to IC 12-7-1-t(n) and IC 6-7.1-12-12(b). File Mark
RUCTIONS: T �
To be filed in erson o� b mail with the Coun Audito� ol the coun where the ro e `�
P y ty ty p p rty is located �� 1�., �
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to 6e eNec �ve.
2) Mobile Homes assessedunder IC 6-1.1J: Between January 15 and Maich 31 of the year the ded��o� i� te� bY�e((ective.
OUL
See reverse side !or additional instructions and qualifications. „ ,.
of applirant
GIBSON
No, whallj,$)his/her ezact share of interest? It owned with someone other than spouse,
indicate with whom
�Li'es ❑ No �
name on record is difterent than that of applicant, indicate
Name o( contrad seller
Is the properiy in question:
❑ Real Pmperty ❑ Mobile Home (IC 61.7-
as defined in IC 12-1-1-7(n) and IC 6-1.7-72-12(b)? Is appiicant disabled and unable to engage in any subst ntial gainful aCivity
. as defined in IC 61.1-72(d)? �
❑Yes ❑No
❑ No
Is the property used and occupied primanty for hisRier residence? Does the applicant's taxable gross income for the preceding calendar ear
� exceed 577,000?
CI Yes ❑ No ❑ Yes o
Tauing district � Key number / Legal desaiption Record number Page number
C� � C` �-/_-��8-� o�
INVe certify under penalty of p' ry that the above and foregoing information is true and correct and that the applicant was a resi-
� dent of Indiana and owner of the aforementioned property on March 1, 20 _
u