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� APPLICATION FOR BLIND OR DISABLED PERSON'S
, - . DEDUCTION FROM ASSESSED VALUATION
• - �� Stale Form 43710 (R919-08)
�a J
P'asaibed by Uie Department d Laml Grnemment Ffunce
'lnfamation containetl in Ihis doaimen� is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
COUHTY TOWNSMIP YEAR
1 � �
File Mark
�NSrnucnoNS: DEC 2 1 2u�u
To be filed in persm or by mail ri(h (he Cou�tyAUOitor ol Ne county where Me property is bcated.
Filirg Dafes: i) Real Property: Ounrg the year /or which the deduction is soughf.
2) Mobile Hwrres assessed uMer IC 67.1-7 w Manufactured Hwrres nIX assessed as Real Pmpeity: Du �����nontlis 6e/ae
Maich 31 o7each year the iridividual wishes to obtain the deduction. GIBSON COUNTY AUDITOR
See reverse side for addAanal insfrudions ari0 qualifications.
Nameo(apM��y� orcantractbuyod
. / l n . . /7 ° . i,
k aavsmm ure sc�141eqa� «ea���ade
u riama m
�
LJ Yes u No �
EiCerem tl�an Umt d appGmn� intlicate
I!L'/.���
, /� / .j
��
Ls applimM Wind as de5ned in IC /2-7-2-21(7y!
� na awaM �sm and omaee
Yes
No
❑ Yes ❑ No
W�Id115 �LSI}IIN 8S8d 5�12(B
Key numoer I Legal desmiplion
C amad wilh somema oNer Wn sGam.
inOitalB wilh who�rt
r orwa,y � aue�,:
��Y ❑ %���YAssessed
AAO6de Flortie (IC 6�1.1'�
Is applioM disaCled aM unada to arqage in a�ry wbstant¢I gainNl atlivCy
as defined in IC 61.7-12-N(d)7
❑ Yes ❑ No
Does �ha aPd�m's laude grnss irKmre for IM preced4g nlendar y�r
e:�e sn.000a
_�r i.� iai- a o3. y��-
❑ Yes ❑ No
Recrnd Inmber Paga number
IIVJe certify under penalty o( perjury lhal the above and foregoing information is tme and correct and that the applicaN was a resident
of Indiana and owner of the aforementioned property on March 1, 20
$ignature W appGanl
Addrcss ol applimm (manbrr antl sEVel. ary. slaM. and ZIP mdc)
Peeress W authorized represen"fatiyc f�mm�0ar aM s4ecf, cdy, sfate, aM LP wct)
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