Disabilty_Gayer°"' APPLICATION FOR BLIND OR DISABLED PERSON'S
- - DEDUCTION FROM ASSESSED VALUATION
� �� - S�a� Form 43710 (R919-08)
�� s'
�'�' Presaibed bY �e Dapanme�u o( Loml Govarrvr�enl Fnarr.e
formation contained in t�is doaimeni is CONFIDENTIAL pursuaN m IC 6-1.7-12-12(b).
INSTRUCTIONS: ,=` C ���
To be hled m person or by mati wit/� fhe CoimtyAUditor o! the crounly where tlre property is located.
Filirgbams: 1) aea�Propedy Dunnq u,e year�or wnid, the deducrian is swynt QIBSON COUNry A p��
2) MoG7e Homes assessed uMer IC 6-1. f-7 or Manufactured Homes rwt assessed as Real Properry: Dunrg the hv��'re}M[�n�s befwe
March 31 d earh year tl�e individual wishes lo o6tain the tleduction.
See raverse sMe lor atltldional instnidions antl pualificafbns.
Name o( aPPGCaN (w�rer � contrau 6vye0
Is aVG&aM Ihe sde
tl rema m remrd u
Name d carilrx] se0er
amef! � tl No. wfial
Yes LJ No
AdEress af mntratl s¢�er (manAvlard sbod. M: sbN. and Z/P G»do)
Ls a0G6mN �nd as CeEned in
❑ Yes � No
� Na oroaam �a ar�a or�.,daa v�Mi br n�n»r r�se�?
❑ No
\ I
�merese!
7 �5�
If Ml1BE WIIII 90TBOfIB dI1B! UNII SOd�SB.
rtb1G2�B WIV1 N'�UT:
Ls Ihe nwaM �^ auastion:
� R��v O a,�ern��a
nnotaa H«r,e ��c s-i.ia�
Is appliram disaWed and unable to e`gage m arry v6sfarLLial gainlul aaiviy
as defined in IC 67.1-12-11(d)?
Yes U No
Wes Ure aPP�M's �axable gra5s "u�cbne br�he P�eCMi^9 tllanGaryear
ezcaed 577.0007
❑ Yes No
num0er I Legal desaiplion Recwd number Paga number
o-u-� �-ti oo �0 3 I 7�-C�a
IMIe certify under penalty of perjury lhat lhe above and foregoing information is We and conect and that the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
applimnl (menber antl sbeef, tiry, sta�, aM
� go �
d authonzed representative � P4drass of autMnzetl representative (nwnbev and shcel, city, sfalc, an0 ZlPcoda)