Disabilty_Adkins- -�'°
�"`�'° APPLICATION FOR BLIND OR DISABLED PERSON'S
;. ; ! .DEDUCTION FROM ASSESSED VALUATION
� Stata Form 43710 (R / 9�%)
�'� �a � PrescribeE by tha State Boartl of Tu Commissioners
In, tlon contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-7 (n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING:
COUNTY TOWNSHIP YEAR
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To be liled in person or by mail with the County Auditor ol the counry where the property is loca-
ted during the 12 months be%re May 11 0l the year the deduction is to be e!lective.
See reverse side lor additional instructions and qualifications.
or
If name on record is different
contract
\,
Yes ❑ No �
Ihat of applicanL indicate beiow
MAY 2 4 1999
�l`�j] �`� GIBSON COUNTY FUU��vn
his/her exad share of interest?. If owned with someone other than spouse,
indicate with whom
Is appiipnt blirW as defined in IC 12-1-1-1(n) and IC 6-1.7-12-12(b)1 Is applicant disabled and unable to engage in any substantial qainful activiry
as defined in IC E7.7-12(d)? ❑ Yes ❑ No
❑ Yes No
Is the properry used and occupied primarily, for his/he� residence? Does the appliwnPs taxable gross income for the preceding calendar year
ezceed $17,000?
� Yes ❑ No ' ❑ Yes ❑ No
Ta�cing district Key number / Legal description � Record number Page number
� �D�S_D_C�O� 9 =o;a
I/We certify under p alty ot perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned property on March 1, 19
of authorized representative (by ezecuted Power o/
�
applicant ` - ' � � � � Address ot authorized representative
#� Uo�. 94 ��l� zt �.Ta � I�. � y