HomeMy WebLinkAboutDisabilty_Black��'� "af APPLICATION FOR BLIND OR DISABLED PERSON'S couHTV TOWNSHIP rEaa
,. ` DEDUCTION FROM ASSESSED VALUATION
,� Sia�e Form 43710 (R7 I 5-06)
Presa�bed by Ihe DeparGnmt d Loc�l Govemmem Finance
��nfwmation contained in this document is CONFIDENT�AL pursuant to IC �2-1-7-1(n) and IC 6-1.1-12- ). FI �� ark
NSTRUCTIONS- � �IOV O s ZOOH
To be (led in person or by mail with !he County Auditor ol the county where lhe property is locate
Filing Dafes: 1) Real PropeRy.' During the 12 months 6efore June 17 oI the yea� the deduction is to 6e eNective.
2) Mo6ile Homes assessed under 1C 6-1. iJ: During the 12 months 6efore March 2��� ndividual wishes to
obtain the deduction. a �
See reverse side for addifional instructions and oualificafions. GIBSON COUNTY AUDITOR
Name of applicant (owner o� contract buyer)
� �� �
Is appliwnt the sWe legal or equitable mme -
� s ❑ No
If name on record is diHerent than that of appliwn
Name of contracf seAer
Address of contract seller
applicant blind as defined in IC 12-1-1-1(n) and
❑ Yes �
ihe property used and occupied primarily (or his
❑ No
distnct
No, what is hislher
vnih someone
with whom
Is the property in questlon:
Ihan spouse.
❑ Real Property ❑ Mobile Home QC E7.1-7)
7-12-12(b)? Is applicant disabled and unable to engage in any substantial gainful activiry
as defined in IC 6-1.7-72-71(d)?
Yes ❑ No
cidence? Does Ihe applicanPs taxable gross income for U�e preceding calenda ear
exceed 577.000?
❑Yes o
number / Legal description
%. �
number
IMJe certify under penaliy 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 aforemen[ioned property on March 1, 20
applicant
e ��
Signature of
represeniative