Disabilty_CulverAPPLICATION FOR BLIND OR DISABLED PERSON'S
- : DEDUCTION FROM ASSESSED VALUATION
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siam Fam aa� to (av i vua�
���• � rresrnhed ny ihe oavanme�a d Lod co.emmem F(unce
tormatiom m�faine0 in Ihis document is CONFIDENTIAL pursuanl lo IC 6-1.1-12-12(b).
couNn TOWNSMIP r�u
a
�NSrnucr,oNS: FEB 4 2p11
To be Filetl "m person w by mail wvlh Ihe Cwn�tyAuditor o/ the co'mty rTrere Me property is bcated.
Fdiig Dates: 1) Real Property: Ourng the year fw wh�ch the deductiai is saght. r K�-�
2) Mobile Homes assessed under IC 6-1.1-7 or ManNactureU Homes rrot assessed as Real Propei7y: Dunrg�fRe lwelve (f41 r�d�lhs be/aa
March 31 W each yearlhe i�ivitlual wishes tn obfein fhe deduction. �v V�
See reverse side !or add6ional insWCGOns a�M qualificafioni GIBSON COUNT � Nuv� ��+� �
N, f ap �r�t (awnar or cmtracf bvyerJ �
�
Is appfim Iha sde uitada ovmeR tl No, what is hivhar esac] shara d"v�terasY! tl a�meE wilh mrtieme allrer Ihan s0ase,
md��a �m wnom:
❑ Yes ❑ No
C �ame m recad i5 diCe�eM Nan Vut ot apptirant iMicale b¢M^.
Nartre ot conUar� sedar
ACEress d mntratl saDer (numDd and sCect. ri�: Stdle. a�d LP mde) IS Ihe AoOertY u� Waslian:
C�(R� a�v ❑ a�rn,aurw�es�d
AAo6de Hame (IC 61.1-7)
k applimnt GiM as AefineC in IC 12-7-2-21(1 �? � Is applirant disaClad aM una0le lo argaga in afry wbstanlial painful adiviry
as definetl in IC 61.1-12-17(d�?
❑ Yes ❑ No Yes ❑ No
6 Ne propeM �s� ��+ped primanly for �isRrer residenca? Does Ne apd�M's �axade grnss urpne (or Ufa pratBEing �aleMar year
eztsed Y77,000? '
� [� Yes ❑ No ❑ Yes No
Taxvu� districl Key number f Legal 0¢soiption Remtl num0er Paga number
� - :3n� -�� O
IIWe certify under penal[ of perjury Ihat fhe above and foregomg information is true and wrrecl and that fhe applicanl was a resideN .
of Indiana and owner of the aforementioned property on March 1, 20
SignaWradaPP�^i _ PdCressotapolimm (�mberarMSbeel.ciry,sfale.arWZIPmGO)
1 � �� � �7��
Sig at eN anzedrapresenlative Mdressolauthorizedrepresentalive (numbrantlslieel.cily,sfafe.andLPwOe)