Disabilty_Julian�
., ';�,`.
APPLICATION FOR BLIND OR OISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Slate Fmn d3710 (R7 ! 5-06)
PresaiM,�d 6Y �e Dep3rtmmi d Loral Governmenl Finance
COUNN TOWNSHIP YEAR
� � �
nfwmaiion contained in this documeN is CONFIDENTIAL pursuan� to IC 12-1-1-i(n) and IC 6-7.1-12-12(b). FilO Matk
INSTRUCTIONS: �UL 3 1 ZOO�
To be liled in person or by maii with fhe CountyAuditor o!!he county where (he propeRy is locafed.
Filing Dates: 7) Real Property: During the 12 months betore June 11 of [he yea� the deduction is i� �
2) Mobi/e Homes assessed under IC 6-1.1-7: During !be 72 mon(hs before March 2'ole�year ndc ual wishes to
obtain the deducfion. GIBSON COUNTY Alldl�u�
See reverse side (or additi al instructions and ualitcations.
Name of appliwnt (owner o ontract buye�
a �_ R � � ��.�.�
Is applicant the sole legal or
If name on record is difteren
Name of conVact seller
Address of contracl seller
❑ Yes ❑ No
than that of applicant,
Is applicant blind as defined in IC
❑ Yes
property
district
I( owned with someone olher than spouse,
indicate wiN whom
Is the pmperty in ques6on:
❑ Real Property ❑ Nlobile Home (IC frt.t-7)
n) and IC 6- .1-12-12(b)? Is appliwnt disabled and unable to engage in any subs ntlal gainful activi��
as defined in IC 6-�.1-12-N(d)?
es ❑ No
'(or his/her residence? Does ihe applicanCs taxable gross income for the preceding calend r year
exceed $17,000?
� NO ❑ Yes o
Key number I Legal descripUon Record number Page number
I/We certify under penalty of perjury that ihe above and foregoing information is true and correct and that tFie applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
o( authorized
representative