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APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr T IP v
s- DEDUCTION FROM ASSESSED VALUATION �
� Sta�e Fortn 43710 (R919-OB)
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PrasuibeE by Na DeOa��meN N Lod Gmem`riera F`w�ce �
�Smna[ion oonfaineC in Nis documenl is CONFIDENTIAL pursuant to IC 61.1-12-12(b). File Mar�k$���
lNSTRUCTIONS: C'�'n '—([--\
To be file0 in person or by mail aith the CounlyAudifor o/the oounty where fhe properly is bcafed. v v
Fe;ngDates: t) Rea�Property:Du.ingtheyearlorwhichthedeductionissaght GIBSONCOUNTYAUDITOR
2) Mobile Hanes assassed under IC E7.1-7 w Manufactured Homes rrot assessed as Real Property: Dunrg the lweNe (72) montfis belwe
MamJ+ 31 d eaM year the irdividual wishes to abtain Ne deductipn.
Sse ieverse sde 7a addAional instrudions arid quelifications.
Name of aVP�M (oxnrru conGact buyeiJ
, - L
Is appliont Iha sde legal or ep�itable R tF No, what is " eiacl share of i�rta�esl7 tl owned wit� somaone aher Uun spoum,
mCirate wilh whom
Yes ❑No
u name «i recara is eiflarem wo � m aa7��t ��,d'ra�e mww:
Nama d caNrar� se0ar
PGdress d mnbaa saller (runnDer aid sbeel. rity. smb. aM zIP mde) (�F���,,o,,p�e Tj in queyinn;
` „ "�°' �fO�IY ❑ MfR1a9�If�552S5Cd
T Mobde Horne (IC 61.1-n
Is appfimN OGnd az EeGneG in IC 12-7-2-21(1 �? Ls applimrtl disabled aM unahle to a`qage in arry 5uhstaNial gainWl atiiviry
as definad in IC 61 1-12-11(d)?
❑ Yes o � es ❑ No
Is Ufe G�M useE and occ�P� P^^N^�Y br h' r tesdenca? Does �Ire aGG��M's lavhle gross incana (w Ne P�ecetling ralenAat year
ezmetl 517.0007 '
es ❑ No ❑ Yes �o
�g disiriG Key number I Legal desmip�ion Remrd number Paga number
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IIWe certify under penalty of perjury Ihat ihe above and foregoing information is W e and correct and that the applicant was a resident
of Indiana and owner o( the aforementioned property on March 1, 20
S'gnaWred pplitanl AEdrassotappli�anl �ivanboraMStrnet,ay,s7am,aMZlPmde)
il/_ %9�s E/�S%3dd Se�v7`�/ ��l��c��f�
NredauNonzeArepresenlaWe Arassofauttmr¢edreprasentalive (numdraMsLCet,cily,5af0.andLPwde)
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