Disabilty_Wells, APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION fROM ASSESSED VALUATION
•S . �.... Slala Form 63710 (R9I4O8)
� PtBSaibed by Ne Dapanmenl d Loml GovBrtunenl Finance
�formatbn con�ained in Ihis doaim�t is CONFIDENTI/LL pursuant W IC 6-1.L72-12(b).
COUNTY TOWNSHIP YEAR
MAY 0 ���1P��
INSTRUCTIONS: .
To be filed in perspn w by mai! rith the ComtyAuditor ol fhe county where fhe properly is bcated. �
Fd/rg Dates: i) Real Properly: Dunrg the year /or which Ne Oeduction is soughG (�,�'y�I y
2) Mobile Hames assassed untlei IC 6-1. f-7 or ManufaGured Hames no[ assessed as Real P�vpeRy: Dunr6i�jfie �( 72Lr�g�Ns betae
Malcn sl d ead, yea� ure imlioidua� wrsnes ro oamin u,e deductia,. GIBSON COUNTY AUDI7UIt
See reverse sitle (a aCdd+ortal insLudions aM qualificafians.
NamedavW+am(°"Tq`°rro"vxitvyod . '
Is aPVI'vN Ihe sde iegal
re rema m reooid is
;r�'�
❑ Yes ❑ No I
tha� d appfi�nl, ineiata oeb.-
nmress d��ae �mr �� a,a so-oa. rar. �m. �e z�a wea�
Ls applicant blind as defined in IC 12-7.2-21(7r1
�+a wweM
Yes
❑ Yes
INJe certify under penalty of
of Indiana and owner of the �
No
e+ad
Kay number I Legal Gesaiption
mniema aher lhan spouse.
whom
6 ma o�PaM in 4�stim:
�� Ro�t�, ❑ a,rn,aoy t�sses�
rnoeae r� ��c s-t.i-��
Is appliarh dLSabled aM unable �o erqage in arry wbsfaM'al gaiMul atlivity
as defined in IC G7.1-12-11(E)?
Oors ihe app'uam•s
esceed 517.000?
ra
y Yes U No
eteOing talBMar year
�Yes ❑ No
7 � Page Suyib
ua.r
Ihal the above and foregoing informa6on is We and wvect and that the applicant was a resident
ntioned property on March 1, 20
N appGraM Pddmss of appfi�ril (�aen6er antl stree( dty, sfale. antl ZIP mtlo)
,n,�� , .�, , � � :e.,�.,Qr.� y �� LI S < <S`t" � � �
dauNarizeErepr tative �MdressolaNhaiz representative (numberardsfroei,nly,sfafo,andLPCUdc)