Disabilty_SloanAPPLICATION FOR BLIND OR DISABLED PERSON'S couNn TOWNSHIP reaa
DEDUCTION FROM ASSESSED VALUATION � � �
$mle Fo(m 43710 (R919-08)
' ' J
Ptascribed by ihe Depa�merY d Lad Gmertunent Frarce
infwmation confained in Ihis doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). O CT 4��e��
INSTRUCT70NS:
To be filetl in person or by mad Mith the (',ountyAuditoi ol the wunty wheia the property is bcated.
Fi4'g Dates: 7) Real PropeRy: Durirg the year (w wh1ch the deduction is sought C� C
2) Abbile Homes assessedunderlC 6-7. f-7 wManu/actured Horrres rrof assessed as Real Ruperfy: Dunrg Ure hve7ve (12)�n �s befae
March37WeachyeartheiMividualwishesfoobtainthedeductipi. GIBSONCOUNTYAUDiIVK
See `everse side far addiUonal instrudions arid pualifications.
Name d aDP�� fwnrf u cantrac� DyeQ
�'
is applimril lha sda legal or ada owneR M No, whal o trivher esacl share d irM1mast7 tl awnaE with mmar�a dlrer Ihan spoum,
indiote wdh whom:
❑ Yes ❑ No
G`ama on reard is diCa(anl Nan Mal o( appfipnt iMirate bebw:
Name of cmlad se0er �
nddress d�caa seoer (�n,ea �d snoa. dr. �am. ane ziP roee� �s me aooeM m a�e�,:
� Re� Prq�stY ❑ MrniaOyy Assessed
Ma6de Flortie (IC 6-1.1-7)
!c app6mM blinE as defined in IC 12-7-2-21�1 �? Is applioN daabled aM unade lo ergage in ary substant¢I gaiMul adivEy
u defined in IC G7.1-12-77(d)7
❑ Yes No Yes ❑ No
k Iha properry usad anE occupiaC pnmar�y br hi4har rasde�xa? Does Ihe aOW�nfs tasade grass imm�a for the preced'vg mleMar year
oamed 517,0001 '
Yes ❑ No ❑ Yes ❑ No
i nG Key number I Legai tlesaiption Rcrard number Page number
c
a� - r-/� -/o/-ood.�39�0
IIWe cerlify under penalty of perjury thal lhe above and foregoing infortnation is lrue and correct and that the applicanl was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
re of appGcam Aedrass ot appkam (imr�ba aM sbeot, cdy, sfam, aM ZIP m0e)
- ' , x o?/ � ' �.
nature d a 'zed resenlaL e Aadrass ot authonzetl re senlative umDer antl sUeeC city. sfafe, antl LP coc�)