Disabilty_Decorrevont°'" APPLICATION FOR BLIND OR DISABLED PERSON'S
. DEDUCTION FROM ASSESSED VALUATION
� State Fam 43710 (R9/9-O8)
.� �
Prascribed bY �e DapaNmenl d Lool Go�emmern Frunce
Information containetl in this dacumen[ is CONFIDENTWL pursuam to IC Er1.1-12-12(bJ.
wsrnucnorvs:
COUNIY TOWNSHIP YEAR
+
File Mark
OCT 2 4 2012
To be filetl in person or 6y mail wi(h the CounlyAudltor of fhe munty whele the poperty is bcafed.
Fifirg Dates: 7) Reel Property D'ning fhe yearlcr wh,ch fhe detluclion is saght C.�. '�°—
2) Mobiie Harres assessed uMei IC 61.1-7 or Manu/acLned Homes rwf assessed as Real PYOperty: Dunrg the hve7ve '� mer�hs 6efae
March 31 d each year the intlirvidual wishes to o6tain the deduction. G I BSON COUNTY AUD ITOR
See ieverse side 7or addd'anal insWdions and qualibcatirns.
Name of a0 (owrer a� conbacf 6vyeQ
�Q�
I5 appli�a sde lepal m eduitade wrtieR o. wt�al o' er esacl stnre d imeresY/ C pmed wiN someone Nher ihan spousa.
"cNimte wilh whom:
❑ Yes ❑ No
C fame m remd s diHarant Ihan ttut d appfimn� iMirala belar.
Name of mntraff se0er ,
Mdress d mnttatl mAer (numOw and sbeN. d1Y. sb�. and ZIP oDdo) Is Ne G�WBM in C�Sion
❑ ��v 0 a,�,auva�
� Mohae Fiar�e (IC 67.1-7)
Ls applimm �nE as Cebned in IC 72-7-2-21(7 �? is appicaN disableA and unade �o e�gage in ary wbstar�Gal gaiMUl atlivity
u defined in IC 61.1-12-11(Cy�
❑ Yes ❑ No Yes ❑ No
Is Ihe V�M usad anG awPed W�a^N (w h's!1»r rasEence? Does Ihe aVd�anfs la�mhle gross ircm�a br iha eceding mlenEar Y�r
exwed 517.0001 '
❑ Yes ❑ No ❑ Yes ❑ No
T�ing distrkf Key numbar I Legal desaiplion Remrd number Page number
- � a-OGb.O �.
I/VJe certify under penalty of perjury thal the above and foregoing informalion is W e and covect and thal the applicant was a resideM
of Indiana and owner of ihe aforementioned p�oper�y on March 7, 20
Signature oF appGraN Atldress of apptimM (rnxnDwaM streef, dy, sta�. arMZ/Pwtle) �0 ��
��'' X%o�d Soy�/�SiA�F /10 S% �K�� �66
SignaturedaNhorizeErepresentative Pdtlrassotaulhor¢edrepresanialive (numMra�dsVeel,ciry,slato,andLPCOdc)