Disabilty_Williams'°'°�: APPLICATION FOR BLIND OR DISABLED PERSON'S
r. : DEDUCTION FROM ASSESSED VALUATION
,.
S State Fortn 43710 (R6 / 4-0d)
•+ � Presuibed by the Department of Lacal Govemment Finanie
COUNTY I TOWNSHIP I YEAR
Inf ation contained in ihis document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). � � Fil��vlark;'
I�UCTIOIdS: �i �� :�� �
To be filed in person or by mail wifh the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 of the year the deduction is to be eN�cla�. ��� �� �
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng fhe 12 months before March 2 of each year the indrvidual wishes to
obtain lhe deduction. -
See reverse side for additional instructio
Name of applicant (owner or contract 6uye�)
Is applicant the sole legal or
If name on record is difieren
Name o( contract seller
Address of contrect seller
Is applicant blind as defined
Is ihe property used and occ
�
l�l Yes ❑ No �
than that o( applicant, indicate below
C 12-t-7-7(n) and IC Fr1.1-12-�2(b)?
❑ Yes �No
ed primarily for his/her residence?
�Yes ❑No
%��f]��Q� ��� GIBSON COUNTY AUDITOR
� \ " / � C�C [�(.fJ'rr•'6�
If owned with someone other than 5poU5e,
indicate vnth whom
the property in Question:
�❑ Real Property ❑ Mob1e Home QC G1.1-7)
Is applicant disabled and unable to engage in any substanfial gain(ul activity
as defined in IC 6-'1.7-12-11(d)?
Does U
exceetl
Legal description
-/�-l�-�f03-DO
�Q Yes ❑ No
gross income for the preceding calendar year
❑ Yes ❑ No
I/We certify under penaltfi of perjury 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
of auihorized representative
authorized representative
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