HomeMy WebLinkAboutDisabilty_KLusmeier�_�"> APPLICATION FOR BLIND OR DISABLED PERSON'S
3_., � DEDUCTION FROM ASSESSED VALUATION
1� ` State Fortn a3710 (R4 / 70-0i)
'\.� �� Prescnbed by ihe Department ot Local Govemment Finance
I�`^rmation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-
�RUCTIONS: c
0 oe filed in person or 6y mail with the County Audito� o/ the counry where th p F
Filing Dates: 1) Real Property: During ihe 12 months before May 11 of the ye he �
2) Mobile Homes assessedLnder IC 6-1.1-7: Behveen January 15 and
See ieverse side for addrtional instructions and qualifications. _ ,
❑ Yes ❑ No
If name on record is different than that of applican
contract selier
as
If No, what
I COUNTY � TOWNSHIP YEAR
(
��TERED F + e Mark
to fi I cc ta e for transfer •
d. __
on �s o e eflective.
� f ear the dep�� is to be effective.
� Gibson Cuun,y
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v'
ur�Tti� �u�,
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If owned with some other than spouse,
indiwte with whom
Is the property in question:
❑ Real Properiy ❑ Mo ' e Home (IC 67.1
(n) and IC 6-1.7-12-12(b)? Is applicant disabled and unable to engage in any s stantial gainful aaivit
as defined in IC 67.1-12(d)?
❑ Yes ❑ No I �Yes ❑ No
Is the property used and occupied primari r his/her residence? Does the applicant's tazabie gross income for the preceding calend
� exceed 577,000?
es ❑ No ❑ Yes �
Taxing district Key number / Legal desaiption Record number Page number
IM/e certify under penalty of perjury that the above and foregoing infortnation is true and wrrect and that the applicant was a resi-
dent of Indiana and owner of the aforementioned propeRy on March 1, 20 _
W
li '
.