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