Disabilty_Bajzath_ . . . .. . . . . ..i .. . .. '
Y APPL�CATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fpm 43710 (R919-08)
S /
Prescribed Dy Ne Deparirtrent d Loml Go�errurenl Fifw�ca
�formation eontained in this docurt�ent is CONFIDENTIAL pursuan� to IC 67.7-12-12(D).
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(NS7RUCT/ONS:
TobefileUinpersonorbymailwifhtheCountyAuditoroftheoountywhe�ethepioper(yisbcated. GIBSONCOUNTYAUDITOR
Fdiry Dates: 1) Real Propeiiy: Dunng the year for which the tleduction is sotghf.
2) Abbile Horrres assessed under IC 6-1. f-7 w Manu/actured Homes irot assessed as Real Roperty: Dunrg !he hveNe (12) monfhs 6etore
March 31 d each year tlie individual wishes to o6tain fhe Uedi.cfion.
See reverse side fur addd'pnal instiudions aM q�a/ificafions
I Nz'"¢ °f aPVGCaN lwnwr or cmf�:d . /1 .. /
ts appliraM the sde lagal or
n rurne an raoora ¢ d'Aeram
Narne d conUw seDer
s.�n rcao,�o
Yes ❑ No
�f appfiont �Mifate betr+-
AOtlrass d mntra�l seAer (menGrr and strcct. uN. sfalo. and LP codej
Ls appGCar4 bfind as
❑Yes ❑No
Ls Iha O�OeM used aM occuPed O�maM' for �idher restlenca?
❑ Yes ❑ No
num�er
-
a vqerasn u ow�m v.;N so�reaie alher u�an scwse.
iMimle whh wtqm:
.I-s -Ih�/e �popeM in question:
� �?! �'O�Y ❑ M�Ud��SS2S5Cd
� MOhde FIOrn¢ (IC 6-1.1-7)
Is applirant disabled an0 urfabla W ergage in arry substarlial gaiMul aCivity
a defined in IC &1.7-12-71(d)7
❑ Yes ❑ No
Does 1tre appicanTS IaraNa gross incorne br tha precedvg nlenEar year
esmed 477.0007
❑ Yes �No
RemrJ number f Paqe numDer
IIWe ceRify under penalty of perjury thal the above and foregoing in(ormation is [rue and wrrect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ ^ , � ��
sy�awre
ofauthonzed eapresentativa
aPPtimnl (mwn0� aM sboe(. rAy. sta�. aM
x /�.�'�1�� �� S
P4tlressofaullrorizedraprasentatrve (nwnDaraMsheet,crty,slafo.andLPcodc)