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� APPLICATION FOR BLIND OR DISABLED PERSON'S couN sni r
DEDUCTION FROM ASSESSED VALUATION
•, �� j 560a Fartn s�710 (R919-08)
Prastn00E by Ihe Oepartment d Loml GOVenurieni Fnance
�� ieMa
Irrfnmation oontained in tltis doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
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To be filed in person or by mail with fhe CountyAudilor o/ the munty wfiere the properfy is bcatetl. v v
FrtiigDates: 7J RealProperty:DunrgtheyearforwhichNeOeductionissought. GIBSONCOUNTYAUDITOR
2) Mo6ile Hpnes assessed unOer IC 61.1-7 or Manu/aclured Homes nW assessed as Real Roperfy: Dunng the hveNe (72J monlhs 6elore
Maich 31 d each year fhe iraividual wishes to obtein fhe deduction.
See reverse side far atlditional insWCtiorts aM qua/ifications
Name af zOP�ward ( or tonbac! 6v1QO
W /�...� �
� aav�m me w� iepai o� ea��wda ow.�n rc wo. .na+ ���. a=aa snara d en�n u o.,�ad wnn :o„g«� an� ua� :oo�+�.
indi�e with whom:
❑ Yes ❑ No
H name is diUareM tlun Nal tl appGmnt, iMicate bebw'
� ��,
'' lLLl� `rKJ �
Pddress d mnhad se0ar (mm6erantl sG'ee+. dty. sfab. an0 LP mEe) Is N propeey in quaslion:
Rea�Froperty ❑ nrvn,aoyAssessed
Mohde Hane (IC E7.1-7)
Is appGrartl bfind a dabned in IC 12-7-2-21(tr Ls applimrtl disableA anG unada la eryage in a�ry �bstantial gairdul atlivqy
as defi�d in IC 61.1-72-17(d)?
❑ Yes ❑ No ❑ Yes ❑ No
Is Lhe WeOeM used aM arvP� P�^N br his/ttier resd.+�ce? Ooes Ihe aPapaM's IazaDle grvss irrnma br Ihe P�ecsaing raleMar year
ezmeE 577.0007
❑ Yes ❑ No ❑ Yes ❑ No
dislricl Keyrwmber/Lagaldesaipfion Recordnumber Pagenumbor
- - a- 3�a- �
IIVJe certify under penalty o( perjury that lhe above and foregoing information is true and correct and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20
Signaturedapp&anl Pddmuofappluanl (incnberarrtlsbeet.aty,sWfc,antlZlPCOtic)
� �04 � � S+. Owen � : !�P r�/. ��t��s
Signature olaNhorized ra resentative Pddrass of auttrorized representativa (num�rraM sGeef, cRy, slale, antl ZIPCOOe)