Disabilty_Kohlmeyer�"°"' APPLICATION FOR BLIND OR DISABLED PERSON'S
:y _ � DEDUCTION FROM ASSESSED VALUATION
State Fartn 63710 (R / 9-96)
t' y�� � PresmEetl by the Siate Baartl of Ta. Commissioners
,... rtnation contained in ihis dceument is CONFIDENTIAL pursuant to IC 12-t-1-t�n) and IC 6-7.1-12-72(b).
INSTRUCTIONS FOR FILING:
To be liled in person c � by mail with the County Audiror ot the county whe�e the property is loca-
COUNTY TOWNSHIP yEAp
File
MAY U a 2001
ieu uunny um ic m�uu�� ucw�c rv�ay � � w uie yeai u�e uewcuun io m ue euecuve.
See reverse side lor additional instructions and qualilications.
Name ot applicant (owner or contract buyer) GIBSON C UN7Y AUp�TOR
� �
Is applicant the s e egal or equitab�e owner? If No, what is his/her exa share ot interestt If owned with someone other than spouse,
indiCate with whom
es ❑ No '
If name on record is ditterent than that of applicant, indicate below
Name of contract s Iler �
� �
Address of cont ct seller � -
Is applicant blind as defined in IC 72-1-7-7(n) and IC 6-1.7-12-72(b)? Is applicant disabled and unable to engage in any substantial qainful aciiviry
� / as defined in IC 6-1.7-72(d)? ❑ Yes �IVo
❑ Yes L�
Is the property used and occupied primarily for his/her residence? Does the applicani's taxable gross income tor the preceding calendar year
exceed 517.000?
� es ❑ No ❑ Yes QPl�
Tauing dis�rict Key number / Legal description • � Record number Page number
�Pi►� (�t�-�-oo3-sv8=t���
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 �
Signature of applicant Si9nature of authorized representative (by executed Power olAttomey)
� Q l� ,
Addres f applicant Address of authorized representative
� � � �O � �%�l ( /�R �1 C i S C'o rN. �