HomeMy WebLinkAboutDisabilty_JohnsonAPPLICATION FOR BLIND OR DISABLED PERSON'S
-- . DEDUCTION FROM ASSESSED VALUATION
- SIaIe Fdm G3710 (R9 / 9-08)
i
�» arescnnee cy ma oacanmem d �od cmem„e�n Firurre
�fwmatiom m�tained in this Aoaimeni is CONFIDENTIAL pursuaN to IC 6-1.1-12-72(b).
INSTRUCTIONS:
IP YEAR
APR 1 5 2011
C.'J.
Mark
To6efiledinpersmorbymailwi(hNeCountyAuditao7thecauntywheretliepoperlyisbcated. GIBSONCOUNTYAUDITOR
Fding Dates: 7) Real Property: Dunng the year for wh�ch the deduction is sought.
2) Mobile Homes assessed under IC G7. f-7 w Manufacfured Homes nW assescetl as Real Pruperty: Durirrg fhe IweNe (12) rtronths betore
Maic/r 37 o/each yearthe iMivitlual wishes to o6fain the tleduction.
See
❑ Yes ❑ No
H narne m remrtl is d9areN ttan W t of app6ra�t iMirate heb.v.
Name d mMrad se0er
Address d mnbatl se0ar (mxnDei and sEOeG uty. sAfo. and ZIP oodo) �Is -Mya�propeM in QueSion:
. 1 � P� �(O�IH ❑ f�/ifkl2�y flS52S5C�
� Ma6de I-lome (IC 67.7-n
k applicam �nd as Aefined in IC 12-7-2-21(1 �? Is applimnt disabled antl unable lo ergaga in arry subsfamial gainful adivity
as defiered in IC 6L1-12-77(d)?
❑ Yes o � es ❑ No
Is Ne O�M usad aM mvped Pma�N Iw hrsRier rasEence? Dors ihe aVWicanl's taxa6la g�oss "vwre br G�e�ed"�9 �IeMar year
ezmeC 517.000? .
s ❑ No ❑ Yes o
rip . Key mimber I Lepal desaiplion Recrortl number Page rwmbar
-.3 - c� �6a Ga
IIW certify under penaity of perjury thaf the above and (oregoing information is true and cortecl and that fhe applicant was a residenl
of I diana and owner of the aforementioned property on March 1. 20
Signature of appGCaril AGtl�ass of appli�anl (ruimbnaM street, city, stam, aM ZlPmde)
� 3z�d' E°
SignaWre d authonzed re esen ative Aearess of auttwrizad reprasenlative (num0oran0 sfree( crty, sfafe, an LPcotle)