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Disabilty_Pickens�(j� 5'"� ' APPLICATION FOR BLIND OR DISABLED PERSON'S COUN7Y TOWNSHIP YEO.rt � " �.,�`'s DEDUCTION FROM ASSESSED VALUATION ^ - �` j State Forzn 43770 (R7/ 5-06) � Presai6e.d by tlre DepvVnent W lorai Government Finance � �Intormation contained in [his documem is CONFIDENTIAL pursuant to IC 72-1-7-7(n) and IC 6-i.t-72-72(b�. ,vsrRUCnoNS. MAY 0 6 Z009 To 6e liled in person or by mail with !he County Auditor o/ lhe county where the property is located. Filing Da7es: 7) Real PropeRy: During (he 12 months 6efore June 11 0/ the year the deduction is to be eftective. 2J Mobile Homes assessed under IC 6-1. 7-7: During the 72 months be(ore March 2 of each yea� ' �v w�shes to obtain the deduction. See reverse side for additional instructions anAmmlifir.a�inns GIBSON C� T� iTne ame of app��wne� applicant the wle legal or name on record is differen buyer) n , owneR ❑ Yes ❑ No � an that of appiicant, indicate below I5 appiicant blind as defined in IC 12-1-1-1(n) and IC G7. property distriG ❑ Yes p No ed primarily for his/her residence? Yes O No Key exact interest? 1 t disaWed in IC 6-1.1 vnth someone with whom Is Ihe property in quesGon: than spouse, Real Property ❑ Mobile Home (IC G1.1-7) � lo engage in any substantial gainful acliviry � Yes ❑ No gross income f—ror e pr��cal ❑ Yes ❑ No Record number Page nu year fQGee certi(y under penalty of perjury that the above and foregoing information is Irue and correct and that the applicant was a resident of Indiana and owner of the aforementioned property on March 1, 20 _ � Signature of applicant I Signature of authorized representative / Atldress o( appGcant ,. Address of auNorized representative ,�— y.;.s� �o s /,v. , y7639 /so E. ��a�� H,. 6 S tp �f ��v