Disabilty_Collins;:
' �1 APPLICATION FOR BLIND OR DISABLED PERSON'S
s. DEDUCTION FROM ASSESSED VALUATION
Siale Form d3710 (R7 / 5-06)
ii
Prewibt,d by Ihe Depatimrn� of Loral Govemmenl Finance
COUNN TOWNSHIP YEAR
F �, I�
nfwmation coniained in ihis document is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-1_b12-12(b). File MOrk
,NSrRUCnoNS: NOV 0 3 2008
To be filed in pe�son or 6y mail with Ihe CountyAuditor o/(he county where fhe property is locafed.
Filing Dates: 1) Real Property: During the 12 months before June 11 of the year [he deduction is to be effective�'%ja� �
2J Mobile Homes assessed under IC 6-7. 7-7: Dunng the 12 months before March 2 0! each year the u(g�viduai �shes to
obtain the deduction. GIBSON COUNTY AUDITOR
See revers side for additional instructions and ualifrca6ons.
Name o( app Wni (owner or conVad bvyeh
n � �r _ 6
n name on recora is tlitter
Name of contracl seller
Address of conVact seller
Is Ne
❑ No
I( No,
indiwte below
as defined in IC 12-1-1-1(n) antl IC 6-1.
❑ Yes ❑ No
residence?
❑ No
share of interest? If ovmed with someone other than spouse,
indicate vrith whom
Is the pwperty in quesGOn: _
�] Real Property O Mobile Home
Is appliwnt disabled and nable to engage in any substantial gain
as defined in IC 6-1.1-12-'11(d)?
.ii�f �.�-iiixi� �
taxabie gross income
❑ Yes ❑ No
� the preceding calendar year
❑ Yes ❑ No
Page number
I/We certify under penalty of perjury that the above and foregoing infortnation is Irue and conect and that the applicant was a resident
of Indiana and owner of the a(orementioned property on March 1, 20 _
authorized representative
Address edappfipnt Address of
� SyzYnl � s� ��roK�- Sti 'i�66 6