HomeMy WebLinkAboutDisabilty_Cain"" APPLICATION FOR BLIND OR DISABLED PERSON'S
. DEDUCTION FROM ASSESSED VALUATION
- � S�am Fmn 43710 (R9 / 40B)
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PreutibeE bY �e Departrtrenl d Loml Govemmenl Finance
�formation rontained in Ihis doaimenl is CONFIDENTIAL pursuant lo IC 6-1.1-12-12(b).
COUNN TOWNSHIP YEAR
ile M ii
INSTRUCTIONS:
To be filetl in person oi by mail wrth fhe Co�ntyAuditor o7the oounty where the properfy is localed.
Fdirg Dates: 1 J Real Property: Dunng the year la which the deduclion is soughf. A P R 2 a( � I �
2) Mobile Homes assessetl unGer IC S7. 7-7 w Manufectured Harres nU assessed as Real Proper(y: Dunrg fhe Avelve (72J months 6efae
Maic/r 31 d each year tlre individual wishes (o obtain Ihe deduction.
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See reverse sde fa adddional insWctions antl qualifications.
Nameo(aV (o�orcpWadbv�crJ �� ✓
% GIBSON COUNTY Au917oR
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Is apV6mN IM svle lagal or e9�a� a.neR H No. what o hisTher ezaa shara d iineresfl M awned wah somew�e olher than s0a+m.
'vdiola wiih whom:
ve5 u No
rc riama m recad is d9amn ihan
Nama W mnlrad se0er
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Pddreu d mnbad se0ar (man6er and stroet �1: stah�. aE ZIP o000)
Ls appliizm �nd az
❑ Yes ❑ No
Ls Na pmpaM �+� anE orri�pied primarily br nNhar resdance?
❑ Yes ❑ No
I Ls the properry in questim:
�R��Y � Mr�uaOYAsse�d
Mohde Hmie (IC G7.1-7)
Is applimnt Aisa�led and unable to ergage in arry substarrtial gain(ul aaivity
as defined in IC 61.b12-77(E�?
❑ Yes ❑ No
Does Iha appGwnfs taxade gross incwna (or Ihe preceding �alendar year
ozmeC 517.0001 '
nGer I Legal Eesaiption Recrnd number
CY o?O �t� - �0. �/-Q
❑ Yes ❑ No
IIWe certify undei-benalty of perjury lhat Ihe above and foregoing infortnalion is true and correcl and Ihat Ihe appiicanl was a residenl
of Indiana and owner of the aforementioned property on March 1. 20
5gnaturaofappGmm l
� Si natura ot aNhorize0 rt
Pddrass of applianl (mwnbr� aM sbeW, tiry, s1a�, and LP mde)
X �Gy3.E. Ysz�x� �Au�iSno S� �l7G
AACrass ol au�horizetl represenNtive (numDer an0 sbeet �y. slale, anE7JPco0c�
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