HomeMy WebLinkAboutDisabilty_Larkins� ��1 APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr TOWNSHIP renR
s. DEDUCTION FROM ASSESSED VALUATION
�` Sfale Fortn d3710 (R71 SO6)
Resaibed by the DepaN�m��t of Loral Govemrnent Finance
Informafiom m�tained in �his document is CONFIDENTIAL pursuant [o IC 72-1-7-1(n) and IC 6-1.1-12-12(b).
INSTRUCTIONS: �
To be liled in person or by mail with the County Audi(or o7 the county where lhe properly is located. � � T 1 5 Z���
Filing Dates: 7) Real P�operty: Du�ing the 72 months be(ore June 77 of the year the deduction is to be eKecrive.
2J Mobile Homes assessed unde� IC 6-1. 7-7: During the 12 monfhs be(ore March 2 of eac�e.��ual wishes fo
obtain the deduction.
See reverse side for additionai instructions and ualifica6ons. GIBSON COUNTY AUDITOR
Name of applitant (ownei or conVact 6Wed
�'
or
❑Yes ❑No
name on record is dif(erent ihan that of appliwn
Name ol conVaG seller
P.ddress of contract seller
Is appliwnt blind as defined in IC 72-7�
❑ Yes
Is Ne property used and occupied prirt
' �[%� H"""'-.c.�
No, whai is hislFier
below
If owned with someone olher than spouse.
indicate wiU� whom
Is the property in question:
6'�eal Properiy ❑ MobAe Home QC 61.1-7)
1-1(n) and IC 6-1.1-72-72(b)? Is applicant disabled and unable to engage in any substanlial gainful activiry
as defined in IC 6-1.1-12-N(d)?
° ❑ Yes ❑ No
arily (or his/her residence? Does Ne applicanfs taxable gross inwme (or Ihe preceding calendar year
exceetl 317,000?
❑ No ❑ Yes ❑ No
Key number / Legal description Rewrd number Page number
6-!/- /9youo- ool. °�-
1/We,certify untler penalty o�erjury lhat the above and foregoing information is true and correct and that the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
representaGve
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oGwnt �
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