Disabilty_WallaceT
�� "�" APPLICATION FOR BLIND OR DISABLED PERSON'S COUr�m TOWNSHIP YEAR '�•
.,,. -- `� DEDUCTION FROM ASSESSED VALUATION ti
- SwteFOrma3770(R/9-96)
� 1 y�� � Prescribetl by the Stare Boartl ot Tar Commissioners
��ormation contained in ihis documeni is CONFIDENTIAL pursuant to IC 72-t-1-1(n) and IC 6-1.1-12-12(b). F r
INSTRUCTIONS FOR FILING: SE P 1 9 2000
To be filed in person er by mail with the County Auditor ol the county where the property is loca-
ted du�ing the 12 months be(ore May i l of the year the deduction is to be effective.
See reverse side (or additional inst�uctions and qualifications. � �� ��
ime of a�(owner or contract
� �
applicant the sole legal or equitable
u name on recom is dmerem tnan tnat
Name of co tract seller
�
Address o contrad seller
Is applicant blind as defined in IC 12-1 �
❑ Yes
/� �° GIBSON
� " /! UG�/
No, what is hislher exact share of
❑ No �
of applicant, indicate below
If owned with someone other Ihan spouse,
indicate wiih whom
and IC 6-1.7-12-12(b)? Is applicant disabled and unable to engage in-any substantial gainful activiry
as defined in IC 6-7.1-72(d)? 'R'Ves ❑ No
7�.
Is the property used and occupied primanly ior his/her resitlence? Uoes the appucam's taxable gross income tor tne precetling caientlar year
, exceed $17.000?
es ❑ No ❑ Yes o
Ta�cin dis rict Key number / Legal description Record number Page number
�,ib�2q 00:(�-obc��r9.=-O��
I/We certity under penalty of perjury thal the above and foregoing informalion is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 �
�77 BFf \ �� �L.. `1> G? D