HomeMy WebLinkAboutDisabilty_ChamberlainAPPLtCATiON FOR BLIND OR DISABLED PERSON'S
,-- ,DEDUCTION FROM ASSESSED VALUATION
-- s�e rorm asno tas r sos)
'�+ � aresamea M Ure oepar6e�nt ot Lom� covemmcnt Flnm�ce
Information contained in fhis document is CONFIDENTtAL pursuant to IC 61.1-72-12(b).
couem rowNSH�a v�e
1 � �j
Fle Maric
MAY 3 2012
�RUCTlONS:
filed in person or by maD with the CountyAuditor of the county whera the property is located. C.�.
wng Dates.' 1) Raal PropeRy: Dunrg the year for whkh the deduUion is sought
2J Mobde Homes assessed under IC Gf. f-7 w Manu/actured Ffomes not assessed as Rea/ Prape�y � Dutrng the 2 months befwa
Mamfi 31 of each year ffie individual wrshes to obtein the deduction.
GIBSON COUNTY AU I OR
See reverse side (or additional instr�tions and qualificafions.
Namie of appikant (owner wmntraa puysd .
/rt �% ,�,� �� /1
ix-v . ,. , � �
is ePP��[ the sde iegal or e9ukable axneR If No. what is hialfier exact share of inierast? Ii ouTed wUh someone ofher than spou.se�
"viCitate wbh ehom:
❑ Yes ❑ No
x reme on �n.e � emerem mm, ma a e�+4 tra�ie oeiwv
Narrm ot mnvaa seum
AECre� ot mntraa seRer lmimber arM aGeet dN. siate, aM LP mOe) 1s ttie property m puestion:
❑ � �P�Y � �+�Y�
tn�e Httre (IC frt.1-n
IS aPP(x�t bi'ud as tlefined in IC 12-7-2.21(1J? Is ap�nt QSahletl aM unade m engage in anY � 9� �Y
az defQred h IC 61.7-12-17(an
❑ Yes ❑ No .�Yes ❑ No
h n,e o�aanr uxd end �aa o� tor wn,m �estda�e? ooea me eav��re �e �s income ror ux a�amd'ms �affi r�
e�o sn.aooT
�Yes ❑ No ❑ Yes ❑ No
' Key numher I Lepal tlesr�tion Remrtl mm�hu Pape rnenber
q,���'-' �O�`v'"> o2�-d v-a'!- 3a3_000. s�b-o.w
UWe certify under pena�ty oi peryury that the above and toregoing informatfon is W e and corted and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Siy�ayrg of app6�l Address oi aAP��m (rwm6er entl abeeL �l: �. and ZIP wde)
9 /1/ /!( r GA2 7 7
Sigrm¢ee d aWwf'¢ed �rtffiive Address of aulhwaeE represe�+tative l r abeeG �: �e. end LPCOde)