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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R6 / a0a) .
Prescribad by the Department of Local Govemment Finance
COUNTY TOWNSHIP YEAR
� �a �
Ir�tion confained in this document is CONfIDENTIAL pursuant to IC 12-1-1-1(n) and �C 6-1.1-12-12(b). File Ma
u ucr�oras: OCT 0 4 2005
7o be �led in person or by mail with the CounryAuditor o( the county where the propeRy is located.
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is to be eH e.
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 o/each a�"r�ie �d7��nal wishes to
obtain the deduction. - GIBSON COUNTY AUDI7pR
Name of applic�,nt (owner or
?CZ0 r �. �--�ZY'
or equitable owner? If No, what is
name on record is difterent
Name
rf contraU seller
a��- �J
❑ No
of appliwnt,
/
blind as defined in IC 12-1-1-1(n) and IC E1.1-12-12(b)?
❑ Yes '�No
Is Ne property used and occupied primarily for his/her
� LKYes ❑ No
district
I with someone other Nan spouse,
with whom
^ I Is fhe property in quesfion:
�iv
�Real Property ❑ Moble Home (IC G7.1-
t disabled and unable to engage in any substantial gainful activiry
trylCy6' 1.1-12-11(d)?
Key number / Legal description
�(�-�..3 �`" �
❑Yes �No
t's taxable gross income for the preceding calendar year
� 0 av
❑ Yes O No
- Paa�
I/We ceM1ify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner ofnhe aforementioned property on March 1, 20 _
�gn�ture of appiipnt � � j'v\ � Signature of authorized representative
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of authorized