Disabilty_White"'" . APPLICATION FOR BLIND OR DISABLED PERSON'S
,. - „,•DEDUCTION FROM ASSESSED VALUATION
S , State Fortn 43710 (R6 / 4-0d)
Prescribed by Ne Department ol Laral Govemment Finance
COUNTY TOWNSHIP YEAR
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In' atlon contained in ihis document is CONFIDENTIAL pursuant to IC "12-1-1-1(n) and IC 6-1.1-�2-72(b). File Ma�k �
ir�ucnoras MAY 2 9 2007
To be filed in person or by mail with the County Auditor o( the county wheie the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be e ctive.�Q�j
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months befo�e March 2 of e ch�y`�r the irt�llvidual wishes to
obtain the deduction. - GiBSON COUNTY AUDITOR
See reverse side for additional instructions and ualifrca6ons.
Name of applicant (owner or cont2ct buyerJ
� �-t_l
Is appliwn e sole legal or equitable owner? If No, what is his/her exact share of interest? If owned with someone other than spouse,
indiwte with whom
Yes ❑ No
If name on record is diRerent �han that of appiicant, indicate beiow
Name of conVact seller
Address of contraG seller Is the property in quesfion:
C�eal Properly ❑ Mobile Hwne (IC 61.1-7)
Is applicant blind as defined in IC 12-1-1-7(n) and IC &1.7-72-12(b)? Is applicant disabled and unable to engage in any substantial gainful acGviry
as defined in IC 6-'1.1-12-17(d)?
❑ Yes o ❑ Yes o
Is ihe property used and ocwpied primarily (or hisRier residence? Does Ne applicant's taxable gross income for the prece ng calendar year
� exceetl 877,000? _
s ❑ No ❑ Yes o
Ta�dng disVict Key number / Legal descrip6on Record number Page number
I Z -O -
IM/e certify 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 of the aforementioned property on March 1, 20 _
Signature o applicant G� /""-/`/ gignaWre of authorized represenWtive
4yrtGi £
Address of appliwnt Address of authorized representative
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