Disabilty_Cooper""' APPLICATION FOR BLIND OR DISABLED PERSON'S
• :. - : DEDUCTION FROM ASSESSED VALUATION
�-� SlafaFOrm47770(R9/408)
�+ d
RascribeE by U�e Oepartmant d Local Grnerrvrenl Frence
o!hiormation oonWineC in this document is CONFIDENTIAL pursuant to IC G7.1-12-12(b).
lNSTRUCTIONS:
��0
! ,' t�'M!■�
� :��
APR 6 2011
To be fi(ed in person or by mail with the CwmtyAudita o/ fhe county where Me properfy is bcated.
Filirg Dates: 7J Real Pioperly: Ourirg the year for which the deduclion is sought. C. �, IY�
2) Modle Hwnes assessetl undei IC 67.1-7 a Manu/acfured Homes nW assessed as Real Roperty: Duing th 72J months 6etore
�tfarch3lNeachyeartlieindividualwishesroobtainthededuction. GIBSONCOUNTYqUD170R
Sea reverse side for adddanal instiuclions aM avdlificafiarrs.
Nama of aV � (owwv or cWrecf bvyerj/�
.J � ^/
Is appfimnl t epuit awneR tl exad share d irrtazes G owned with someone oNar than spoum,
iMil.ate with whom:
L.{�res ❑ No
C(uma m remd i5 CiEB�eN C�an ihal d appfimnt iMipta bebw!
Name of mntrarf se0er
AOtl�ess d mnbad seGer 1mm6er arW streeC cdY• smle. and LP (nde) Is Na M(n Queslion:
e�Pm�rtY ❑ Mrwaq'ASSessed
Mobde Flort�e (IC 67.7-7)
Is applimnt diM as aafined in IC 12-7-2-27(i�? Is applionl disaDled and unable W engage in ary wbslan�ial inlul atlivity
az defined in IC &1.1.12-77(d)?
❑ Yes ❑ No es ❑ No
Is Ihe proparry used and oaupieC priniarily Iw ' r rastlence? Does Ihe a00��M's laxahle gross incoma br Ihe peced'vg rale�bar year
� e+meE 517.000?
es ❑ No ❑ Yes No
T^az'vg dis�� Key number I Legal EesQip�ion Recwtl mimEer Page mimom
\ � O �O
IIWe certify under pena ty o( perjury thal the above and foregoing informa6on is true and correcl and thal the applicant was a�esident
of Indiana and owner of the aforementioned propeAy on March 1, 20
Signalure of apqi�ant Pddrass d appliont (rnrtnDer aM sboc4 �J', s1a2. anO ZIP mdo)
aWre of aumorized rav�esentative AEOrass of authwized reoresentalive (numDer aM sGeet. City, 5alo, and LPCOde)
P �_ .