Disabilty_Gilpatrick� '��" APPLICATION FOR BLIND OR DISABLED PERSON'S CouN7Y TOWNSHIP YEAR
; '.. ; DEDUCTION FROM ASSESSED VALUATION
; State Fortn 63710 (R6l 4-04)
� Prescribed by Ne DepatlmeN of Local Govemment Finance
ir`-^nation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.'I-72-12(b). �
.�ucnoros: APR 1 6 p007
To oe filed in person or by mail with the CountyAuditor o( the county where the property is located.
Filing Dates: 1) Real,Property: During the.12 months be(ore May 11 of the yea� the deduction is to 6e effective.
2) Mo6ile Homes assessed under IC 6-1.1 •7: During the 12 months before March 2 of eact y�er3he:��'evidual wishes to
obtain the deduction. U (J
See reverse Side foradditional insWctions and m�alifiratinns � Q�BSON COUNTY qUBlfi@p
Name of appli nt (owner
Is appli e sole leg
If name on record is diflen
Name o( contract selier
Yes ❑ No
that of applicant,
Is applicant blind as defined in IC 12-1�
❑ Yes
Is the property used and ocwpied prim
0
� i .
what
and IC 6-1.1-72-12(b)? Is appli
. as defir
No
r his/her residence? Does U
exceed
Yes ❑ No
number / Legal description
If owned with someone
indicate with whom
Is the property in quesBon:
spouse,
I� Real Property ❑ Moble Home (IC E1.
.
I disabled and u ble to engage in any subsWntial gainful ac�vi
in IC 6-1.1-12-11(d)? �
'/o%Da�./�3
,�7 Yes ❑ No
taxable gross inwme f r e preceding calendar year
❑ Yes �No
Record number Page number
I/We certi(y under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
ot
ippycant / Address of authorized representative ,.
lo(� S. I���P,�-��..�. ����.�� , s