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""' APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Smfe Fam 43710 (R919-08)
's J
Presaihed by Ihe DepanmaN d l.oml Grnemnem F�ance
�nformatbm m�taineA in this doa�ment is CONFIDENTIAL pursuant to IC frt.t-12-12(D).
INSTRUCTIONS:
COUNiY TOWNSMIP YEAIi
FI
File Mark
OCT 7 2011 ,r�
To be filed in person or 6y mail with the CountyAudifor ol the county whe(e Me piope�ty is loca(etl.
Fifirrg Dafes: 1) Real Property: During tfie year (ar which the deduction rs sougM. C���
2) MoWle Homes assessed under IC Ca1.1-7 or ManWactured Homes nW assessed as Real Property: Dunrg fhe 2J monfhs 6e/ae
March3fo/eachyeartlreiiMirvidualwishesfoobtainfhededuclion. GIBSONCOIINTVniiniTn„
See reverse side /or adddional insWdions arW qualifications. --�--' '"' `
Narne of zOP�iraM (owwrm conGaIX DvyerJ� �
1
Ls eppfioN Na stle la�l or epuilable on�af! M No. whal o hislher aiad share ' e�esYt N owned wilh someoria dher Ihan spoum.
udim�e wifh whom
❑Yes ❑No
tl name m rernd is diQerenl Nan Nal W apqcanl iMirate bebr.
Name d comrarl se0er
PEdress d mnbatl saAer (nun6er aM sDee1 �Y. stalo. aM ZIP mdo) 6 Ne proparty m quesfion
� ��a�v ❑ ��v�
Mohde Home (IC 67.1-�
6 appfimM bfinE as defined in IC 12-7-2-21(1(! ��p�m a�o�a ar�a ��c� m�� � ar�y a�ara� pa�nn aarvay
as defined "m IC 61.1-12-71(d17
❑ Yes ❑ No Yes ❑ No
Is Uie G�OaM usaE anE aaupied PMa�Y br tidher rasEence? Does Rre a00�icam's iawde grnss inmme br the P�e�+B �aMar year
exmetl 517.000't
❑ Yes ❑ No ❑ Yes ❑ No
Saxing isviG Key n�m0er I legal desaiption Remrd number Paga numbm
�yv � -�0-1/ -I DD-DDD_ �/�D /
INVe certify under penalty of perjury lhal the above and foregoing infortnalion is true and correcl and [hat fhe applicant was a resideM
of Indiana and owner of the aforementio�ed pioperty on March 1, 20
Signatura d applwar�t ACdress of appliam (mmDcraM sbecf. nty, uafc. aiM ZIP mde)
� ` 5 S 4? G6
Signature ol aW�orize0 (apresentalrve AdGress of authorized reprasentative (nwn0ci an0 sLec4 �y, 4aie, and ZIP e)