HomeMy WebLinkAboutDisabilty_JohnsonI� °"' APPLICATION FOR BLIND OR DISABLED PERSON'S
,-- ; DEDUCTION FROM ASSESSED VALUATION
S ; SUte Fortn 43770 (R6 / 4-04)
�Prescribed by fhe Depanment of Local Govemment Firiance
I`
COUNTY TOWNSHIP YEAR
� � �~�
I�6on coniained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). Fi e��ark'"`�
�. ucnoros: JUN 0 5 ZU,;;
To be filed in person or by mail with the CountyAuditor o/ the county where the property is located.
Filing Dates: 1) Real Froperty: During the 12 months 6e%re May 11 of the year the deduction is to be elf ��ve.
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before.March 2 of each'ye�sr`Mi�Bividual wishes to
obtain the deduction. GIBSON COUNTY q,�;;;; _-
See reverse side for additional instructions and ualifrca6ons.
Name of appyq�nt (owner or cont2ct buyp.�)
appiicant the sole legal or
name on record is diBerenl
ame of contract seller
ldress of contract seller
applicant blind as
what is hishier exact
Yes ❑ No �
that of applicant, indiwte below
I with someone
with wham
Is the property in
spouse,
Real Properly ❑ Mob�1e Home
C 12-1-1-1(n) and IC G7.1-12-12(b)? Is applicant disabled and able to engage in any substanlial gain
as defined in IC 6-�.1-72-71(d)?
❑ Yes O No ❑ Yes O No
ed primarily for his/her residence? Does the applicanYS taxable gross income for the preceding calen
exceed $17,000? �
Yes ❑ No Yes ❑ No
� Key numbe/r Le I description Rewrd numb Page numh
d�o�/��o �ea��a- � ib'
61.1-7)
year
I/We ceAify 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 _
of
Address of
a! 3� ,� . 45a
Signature
Address