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° APPLICATION FOR BLIND OR DISABLED PERSON'S
- DEDUCTION FROM ASSESSED VALUATION
� Sta9e Fartn 43710 (R9 / 9-08)
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�'� Presaibed by Ne DaOa��� N Loml Gwemfrenl F(urca
formatbm m�tainetl in Nis tlowment is CONFIDENTIAL pursuant to IC 6-7.7-12-12(b).
INSTRUCT70NS:
�l
To 6e filed in person or 6y mail with fhe CaxqyAUdRw o7the county wM1ere fhe properly is locatetl.
Fdirg Dates: - 1) Real Property.� Dunrg Ne yearla which the deduclim is sotghG JUN 2 1 2010
2) MoW7e Hmies astessetl uMer IC 6-7.1-7 0� Manufectured Hwnes nU assessed as Real Propeity: Dunng fhe 1weNe (12/ months 6efore
.' ' " ' . .. . .. .. . . . . .. . .. . . _
maiw o� w nau� ynar u�n rturvruuai msnw w wwrn me aeaucwn. �
See reverse side for adddional insWdrons aM qualifications. �
�aeao�"!°K*���^o-�ua+wo GIBSON COUNTV A�pITA(�
N the Iegai m epuilade awneR tl No, whal a hisTher esact ahara d iMerasY! G oxired wilh wmea�e dher ihan spouse,
cdimte wilh whom
❑ Yes ❑ No
C name m ramd's diCareN Can Ual d app&anl iMirate bebw:
Name ot wnlrnd se�er
MCfass d mntrad se6ar parnOei ard strocG dry sbb. aiM LP wtle) Is e prapaity in que5iort
r2e�aro�erty Q nnrn,a9ynssessea
Mohde Florne (IC 61.1-7)
s aov��rrm tfim as eeEnee m �c 12-7.2�2y1 �7 � Ls aod�'am eisabled and unada ta e`gage in anr su6swY;a1 gairiw� aan;ry
a tlefined'm IC 61.1-12-71(dl?
❑ Yes ❑ No ❑ Yes ❑ No
Ls Ne M�M used anC oavped P��ma�T/ lor hislher maCexa7 Does ihe aPqiraN's lazable gross incane for the 7�arad'vg raleMar yaar
ex�aed 577.00M '
❑ Yes ❑ No ❑ Yes No
Gsing d' rifJ Key number / Legal desoiption Remrd num0er aga number
- = -- - o3-=G�o:.. - -: - 4 c�,
INJe certi(y under penalty o( perjury that lhe above and foregoing information is tnie and wrrect and Ihat the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
� Signature d appGran1 ��/^ `� Pdd2ss of appliraM (mnnbtr antl sbee4 �: stafi. ard ZIP mdo)
u.e:G�-,�� �� 0 llJ � �i7 �� �' ,
naWrB aNhonzedrapresenlaWe ressafaulhorizedmpresen�alive (numArlandsGeet,cAy,sfafC.andLPcode)