Disabilty_Haley°"'• APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr TOWNSHIP ven,a
•o-- ' DEDUCTION FROM ASSESSED VALUATION
S ;� State Fortn 43770 (R6 / a-04) �
Prescribad by Ihe Depanment of Local Govemment Finance
Inf� •ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-7.b12�). ile ark
I�UCTIOIdS:
To e filed in person or by mail with the County Auditor of the county where the property is located. t
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 0( the year the deduction is td��e�eU[�006
2) Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each year the individual wishes to
obtain the deduction. �� ��
.Cea roverce cirle fnr nrlrli}inn�l incln�rlinnc �n.l nunlifin�Fnnn
Name of
name on rewrd
Name of cont2ct.seller
as
or equitable owner? If No, �i i is hislher exact share
❑ Yes ❑ No
than that of applicant, indicate below
-1(n) and IC�6=1.1-12-12(b)?
❑ Yes C�JQo
the property used and occupied primarily (or his/her residence?
� � No
GIBSON
If owned with wmeone other than spouse,
indicate with whom
Is the property in question:
❑ Real Properry ❑ Mob�1e Home (IC 61.1-7)
Is applicani disabled and unable to engage
as defined in IC 6-1.1-12-17(d)?
Does the applicanPs taxable gross income
exceed 377.000?
number/ Legal descriptlon
'�u•a ��
i any su ntlal gainful activity
es ❑ No
r fhe preceding wlen year
❑ Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of authorized
of authorized representative
2 �\0.J
