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APPLICATION FOR BLINO OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Slaie Form d3710 (R7 / 5 �O6)
Aesuibe.d bY �he DeP'�+��rni N La�l Govemmem Fuwrc
COUNTY TOWNSHIP YEAR
�n(orma6on contained in this document is CONFIDENTIAL pursuant [o IC 72-1-b1(n) and IC 6-7.7-12-12(b�. F
NSTRUCTIONS: � � � ��
To be liled in person or by mail with the County Audilor of the county where the property is locate
Filing Da(es: i) Real Property: During the 12 months before June 71 of lhe year the deduction is to be effective.
2J Mobile Homes assessed under IC 6-1. 1J: During the 72 months be(o�e March 2 o(eacFj��F!!� (rd�l wishes to
obtain fhe deduction.
See reverse side for additional instructions and nrwliFear���� _ �-. __ _..
of applicant
appliCant the sole
name on recwd is
buyerJ
owner?
O Yes ❑ No
Ihan that o( applicant,
Is appiiwnt blind as defined in IC 12-1-1-1(n)
proDerty
❑ No
for his/her
❑ No
exactshare
GIBSON
It owned with someone other than spouse,
indicate with whom
Is the property in
�❑ Real Property ❑ Mobde Home (IC G1.
Is applicant disabled and unable to engage in any substantial gainful acfivi�
as defined in IC 6-1.7-12-11(d)?
�es ❑ No
Does �he applicani's taxable gross inwme (or fhe preceding raiendar year
exceed 577,000?
a G-o b-lP-Yc�-000�
❑ Yes ❑ No
- Paa�
I/We certify under penalty of perjury ihat the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforemenlioned properiy on March 1, 20
of appficanl
�jE ,Soo/!J-
����� �f7Gt��
of authorized represenWGve
represeniative