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�`"' APPLICATION FOR BLIND OR DISABLED PERSON'S couN � SHIP
-� DEDUCTION FROM ASSESSED VALUATION
. ,� � .. Sta�eFarm437101R9/9-08�
wr �
Rasaibed by Iha Daparlmenl d local Gosmmqnl Financa
Information confainetl in Ihis docvmen� is CONFIDENTIAL pursuant to IC 6-1.7-12-12(b). File Mark
lNS7RUCT70NS: C � �' �
To be filed in person w by mail hrth the CountyAUd'ROr of Ure caunty where the pioperty is located.
FiliryDates= 7)ReelProperty:Durirgtheyearlorwh,chthedeductionissaght GIBSONCOUNTYqUp�T�R
2) Mo(�7e Homes assessed �nder IC 61.1-7 w Manufactured Homes not assessetl as Real Property: Ounrg fhe tweNe (72) months betae
March 31 d each year tlie irdividuel wishes to o6lain fhe dedr.clim.
Jee rBVBrse stle tor atltl6mnal msWCLiDns ard qualifications
Na�ne of zGP�blrnnw� � cmbarf
�- �Xix��
Is aPP� mle legal w eQUYabla ownaR If No. is hivher asac] share d cdwest? tl wmaE wrth wrrea�e dher Ihan spou�.
uMiote wilh whom:
❑ Yes ❑ No
M rume m recard is 6darant than Ihat d appficanl iMicale Cebw.
Name of caNad se0er
Pddrassdmntratlse0arliuenbwantlsboW.cip',ffib.aMZ/PmW) I5 O�oGeMinWastion:
a���,,- o �»�,,�,
ti,oeae r� pc �,.,-��
� aucr�m e�ra � a�,m � �c �z-�-z-zili n Ls appliont disa0leE aM unada lo e(qage in arry sibstantial gaiMul adivCy
as defined'm IC 61.14247(E�?
❑ Yes No es ❑ No
Is Iha P�M useE antl oav0� p��aY br � r rasEanee? Does Ihe a70�M's lasa6la grms income br lhe receE"vy ralendar year
eztaed 577.0001
es ❑ No ❑ Yes o
Tazin sUicl KeynumDer/Legaltlesaiption Remrtlnum�er Pagefvmber
- _ o�-aoa. �5�oaa�
IlWe certi(y unde� penally of perjury t at lhe above and foregoing infortnalion is true and correct and that the applicanl was a resident
of Indiana an wner of the aforeme ned property on March 7, 20
Signatu da AdCressofapplirant(�umbeiarqsRee(Uy;s�am,antlZlPmtlo) L
�� (� LJ�Sf ,s%hTt �"ee�'oN
�
ure of au � etl representalive AtlErass of aulhwized representative (numDeiaM shecC city. sfafo, antl ZIPc