Disabilty_Brown°'" i APPLICATION FOR BLIND OR DISABLED PERSON'S coUr�TY TOWNSHIP YEnR
, - _ ; DEDUCTION FROM ASSESSED VALUATION
S ; . .;State Fortn 43770 (R6 / 4-04)
Prescribed by Ihe Department of Laal Govemment finance
Ir \tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-1.1-12-12(b).
,���T,oros: � I �, ��
To be filed in person or by mail with the CountyAuditor of the county where the property is locat
Filing Dates: 1) Real,Property: During the.12 months before May 11 0l the year the deduction is to 6e effective.
2) Mo6ile Homes assessed under lC 6-1.1-7: During the 12 months before March 2 of eaciil}'�"� �jje jn�IQ�ljial wishes to
obtain the deduction.
See reverse side (or adddional instructions and ualifications. �,�
Name of applicant er or contract buyer) v�� � N�
GIBSON COUNTY AUDITOR
Is applicani the sole legal or equitable owner? If No, what is his/her exact share of interest? If ovmed with someone other ihan spouse,
indicate with whom
�s ❑ No
if name on record is difterent than that of applicant, indicate below
Name of conVact seiler
Address of wntraU seller Is the property in question:
❑ Real Property ❑ Mob�e Home (IC 67.1-7)
Is applicant blind as defined in IC 12-1-1-7(n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any substantial gainful activiry
as defined in IC 6-1.1-12-1'I(d)?
❑ Yes O No es ❑ No
Is�property used and occupied primarily for hislFier residence? Does the applicant's taxable gross income for the preceding caiendar year
exceed 517,000? �
�s ❑ No ❑ Yes o
Ta�dng district � Key n�mber / Leg��scrip�� �� 6_ ��� Record number Page number
w r� JJO��I(�'DDI��-00
I/We cerlify 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 _
Signa re of applicant Signature of authorized representative
�
Address of appiicant Address of auihorized represenWtive
DU W s"SD �