HomeMy WebLinkAboutDisabilty_Dougan'°"' � APPLICATION FOR BLIND OR DISABLED PERSON'S couNTr TOWNSHIP ren,R
� - � .DEDUCTION FROM ASSESSED VALUATION
,� ; State Fortn 43710 (R6 / 4-04) ,
Prescribetl by the Department of Local Govemment Finance
Ir tion contained in this document is CONFIDENTIAL pursuant to IC 72-1-1-1(n) and IC 6-1.1-12-12(b). File Mark
6 UCTIOldS: � �
7o be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to 6e effective.�
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each ye��f�e iqdiyi�,a( �yishes to
obtainthededuction. 1 1 UU/
See reverse side for additional instructions and ualifica6ons.
Name of applicant (owner or ct buyer) _ �a�_ �s P
GIBSON COUNTY AUDITOR
Is appliwni Ne sole legal or eq itable owner? If No, what is er exact share of interest? If owned with someone other than spouse,
indicate with whom
❑ ❑ No
If name on record is difterent than that of appiicant, indipte below
Name of contrect seller
� `-�
Address of contrad seller Is the property in quesUon:
� ❑ Real Property ❑ Mobile Home (IC 61.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any substan6al gainful acfivity
as defined in IC 6-1.1-72-71(d)?
� ❑ Yes No �es ❑ No
Is� roperry used and ocwpied primarily for his/her residence? Does the applicanPS taxable gross income for the preceding wlendar year I
exceetl 577,000?
es ❑ No ❑ Yes ❑ No
Tapng dis t Key number! Legal descriptlon Rewrd number Page number
i�'� � � a G-/a-bS -'fob-o� S°5-�
I/We certify under penaity of peryury 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 _
Signature of appliranl Signature of authorized representa[ive .
��
Addkss of appliwnl Address of authorized representative
`(��' 3 13 6 j� � �q �