Disabilty_Pendleton"'" - APPLICATION FOR BLIND OR DISABLED PERSON'S
r, - ; DEDUCTION FROM ASSESSED VALUATION
S ; State Form 43770 (R6 / 4-0a)
Prescribed by fhe Department oi Local Govemment Finance
In -- ation wntained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.7-12-12(b).
I UCTIONS:
To be filed in person or 6y mail wifh the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 0( the year the deduction is to be effective. p E ���
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months be(ore March 2 of each year the individual
o6tain the deduction. /, , i
See reve
� Name of
Is
'�1�/�/ 7'--' (�
or equitable owner? If No, what is hisRier exact
�es ❑ No I
name on rewrd is difterent �han that of applicani, indicate below
of contract seller
as
P�aPerb
-.3oa-ool.4.
1-1(n) and IC 6-7.1-72-12(b)?
GIBSO,`J
4
to
AUDITOR
I with someone other than spouse,
with whom
Is the property in quest. .
-0�� I❑ Real Property ❑ Mobile Home (IC 61.1-
IIs appliwnt disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-'12-1'I(d)?
❑ Yes o
and occupied primarily for his/her residence? Does tF
exceed
Yes ❑ No
Key number / Legal description
I/We certify under
of Indiana and ow
Yes O No
taxabie gross income for e preceding calendar year
❑ Yes
number
of perjury that the above and foregoing information is true and conect and that the applicant was a resident
e atorementioned property on March 1, 20 _
of authorized
[�
of authorized
RR�2
3 %b'(.J. I IV^iCe.%aJ� /,✓