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� APPLICATION FOR BLIND OR DISABLEO PERSON'S
�. DEDUCTION FROM ASSESSED VALUATION
•� j Stale Fortn d37t0 (R7 / 5-05)
COUNTV TOWNSHIP YEAR
.. �'�` � PresaiG.H by Uee Depariment d Local Govemmem Fv�a�xe
\
Information contained in this document is CONFIDENTIAL pursuant to iC 72-1-1-1(n) and IC 6-1.1-12-72(b�. File Madc
iNSrRUCrioNS: MAR 1 2 2009
To be tiled in person o� by mail with the County Auditor ol the county where Ihe property is locafed.
Filing Da(es: 7� Real Property Dunng the 72 months before June 7 7 of the year the deduction is to be eNectiv�-y,,
2) Mobile Nomes assessed under IC 6-L 7-7: During the 72 mon(hs be/ore March 2 0/ each year�Nf�fl��hes to
o6tain the deduction. GIBSON COUNTY AUDIfi9�
share o(
���. with someone other than spouse,
with whom
Is the property in
O Real Property ❑ Mobde Home QC 61.1-
3nd IC 6-1.1-12-12(b)? is applicant disabled and unable to engage in any substanfial gainfui activiry
i
as defined in IC 6-7.1-12-11(d)?
No Yes ❑ No
� his/her residence? Does ihe applicants taxable gross income (or the preceding calendar year
Yes ❑ No
❑ Yes
IIWe 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 _ ,
representative
of appG�Snt . Address of authorized
as'�/��is US