HomeMy WebLinkAboutDisabilty_Kingsburyr � -. - ,-
�` "" APPLICATION FOR BLIND OR D�SABLED PERSON'S � � srtia YEARm
r� -� � DEDUCTION FROM ASSESSED VALUATION
State Fortn a3710 (R / 9-%) �'1
l�.�Cl
�' �� � Prescnbed by the State Board ol Taz Commissioners
i.�ation contained in this document is CONFIDENTIAI pursuant to IC 12-7-1-1(n) and IC 6-1.1-12-12(tl).R �� File Mark
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the prope is loca-
ted during the 12 months be%re May i l of the yea� the deduction is to be eNective. GIBSON COU TY AUD17�R
See reverse side (or additional instructions and qualifications.
Is applicaN the sole legal
If name on record is diHer
Name of contract seller
Address of coMrad seller
s appiicant blind as defin�
s Ne property used and �
orcontraG(buyerJ
�
❑ No
IG 12-1-1-1(n) antl IG 6-7.7-72-12(b)?
❑ Yes ❑ No
ied primarity, tor his/tier residence?
❑ Yes ❑ No
, Key number / Legal
C..� / l�
Is appliqnt disabled and
as defined in IC 61.1-121
Does
73
i SomOOne oth9f thhn SpoUSe,
whom `l
mie to engage �n any bsfantial gainful activity
es ❑ No
gross income tor the preceding calendar
❑ Yes o
Record number � Page number
I/We certify under penalty of perjury ihat the above and toregoing intormation is true and correct and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned property on March 1, 19 _
of applicant
� �
f apPlicant
RR�z 6ox s5
t��bst�t- ��J
representative
Power of Attomey)