Disabilty_Lynch...,,
��. - `-
♦ J
u�.
APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fwm 43710 (R6 / 4-0a) .
Prescribetl by Ihe Depariment of Local Govemment Finance
COUNTY TOWNSHIP YEAR
In`- tion contained in this document is CONFIDENTIAL pursuant to IC 12-7-7-1(n) and IC 6-1.1-12-12(b). File Mark
ii�ucnoros:
To 6e �led in person or by mail with the CountyAuditor of the county where the propeRy is located.
Filing Dates: 1J Real PropeRy: During the 12 months before May 11 0( the year the deduction is to �e�v� �
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months be(ore March 2 of each J U Nt1� i2diujdF�al wishes to
obtain the deduction. - b [UUo
See 2verse side for additional instructions and auali�ratinna
of applicant (owner or
�
No, what is
Yes ❑ No
name on rewrd is difrerent than that of applicant,
Name of cont2ct seller
GIBSON COUN I Y AUV� wn
If owned with mmeone other than spouse,
indicate with whom
Is the property in question:
� Real Property ❑ Mob�e Home (IC 67.1-7)
applicant blind as defined in IC 12-1-1-1(n) and IC E7.1-72-12(b)? Is applicant disabled and unable lo engage in any subslantlal gainful activity
as definedin IC 6-1.1-12-11(d)?
❑ Yes No �Yes ❑ No
ihe property used and ocwpied primarily for hislher residence? Does the applicant's taxable gross income (or the preceding wlendar year
� exceed 517,000?
Yes ❑ No O Yes No
�ixing dis ct Key number / Legal description Record number Page number
,,�C `,�,vfi� o lo =--ro-5 � 7 -o 0
I/We certify under penalty of perjury that lhe above and foregoing information is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
SignaNre o( authorized
of authorized