Disabilty_BoldenAPPLICATION FOR BLIND OR DISABLED PERSON'S courm' rowrest+�r rEaR
,--• DEDUCTION FROM ASSESSED VALUATION
�-, sr�e ra�„ as�io tae i sae>
Presa@�.M by fhe DePartrt�ent of Lxal Go�smnent Fnamn
Infortnation�contained in Mis document is CONFIDENl1AL paisuant to �C 6-�.i-12-12@).
iNSrRUCnoNS: NOV 2 6 2012
To be filed in person or by mad wifh the CountyAuddor of the counfy wheie the property is /ocated.
FAira� Qates.' 9) Real P�operty: Dunng the year Ior which Me deduction is sought ^
2J AfobJe Homes a�ro��+underlC 61.1-7 w Manufactured Hanes nnt assessed as Reaf P�ope�'Ounng�e (12J months before
March 31 of each year the individual wishes to o6tain the deduetion.
Seeraversesideforadditia�alinstnictionsarMqualifirations. GIBSON COUNTY nuui�vn
Name d apqkant ( orm'trsa by�ad ^
` � v � W �-�`�V �-�-/ ' �"
!s eppfrant Me sole �gal or owneYt If N0. what �s fJs/her eYe o( interast? if oxned wuh sorneone other then spdi.a.
'v�Eimte wiU� wfvn:
❑ Yes ❑ No
H nartre an remtl Ls CAfinent tl�an tl�al M aPP�4 trMhste Celow.
Plame ot mrErerS
�
AdOress o1 conVact lnumber aM suaet �: state, and LP wde) 15 the poperry in puesiion:
❑��Y��Y�
tv1�e F�me (IC &1.1-n
is aaa��t br�m az mrmm � ic iz.�-2s��»? ��� ��-arim2-��wmnie m en� m anr ��+� s� �r
❑ Yes �o [�Yes ❑ No
h IM proparty uxd erd oaupted prirtmr@y (on c�/hm residarroa? Dona ihe ePP��re taxabk g�oss i�ome tor tha preceEirg cehndm year
ezccetl 517.OW7
Yes ❑ No ❑ Yes �No
Tadnp distriri . Key numher / Lepal dewiption Remrd numhel Pape rnsnber
�1 �-13-i �-dOa-C�0.3ao �,S
UWe certify under penairy ot perjury that the above and toregoing infortnation is W e and corted and that the applicant was a resident
of Indiana and owner of the aforementloned property on March t, 20 _
apWk�t AdErass of �n(rt (number entl atree4 ctiy, abte. and ZIP wde)
t 02ti �;����G�.- � o� s. r���ti Sr_ �ra,�rc.�s co l"�/ �f7le �9
Syimwre d a�Ma'ved rePr�m�ive Address W eudior¢M representalive (nurtrber end sLeet �l: ffiate, a�M LP mCe)