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ri APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
,; C.,' DEDUCTION FROM ASSESSED VALUATION
State Fenn 63710(R9t9-�)
.F IT
Prescribed by the Department of Local Govermnent Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). ibe Mark
INSTRUCTIONS: MAR 15 2013
To be filed in person or by mall with the County Auditor of the county where the property Ls located.
Filing Dates: 1) Real Property.During the year for which the deduction is sought.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:D months before
March 31 of each year the individual wishes to obtain the deduction.
GIBSON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
Cis Q/C07
Is applicant the sole legal or equitable owner? a,what is his her exact share of interest? If owned with someone other than spouse,
indicate with Whom:
es ❑No
If name on rend is Melva than{{{{{{������of Indicate below:
074,5 r
Name of contract seller
Address of contract sailer(number and street city,state,and ZIP code) Is the property in question:
❑ Real Property ❑ AnnuaDyAssessed
Mobile Hare pC 6.11-7)
Is applicant blind as defined in IC 124-2.21(1)? Is appftoant disabled and unable to engage in any s bstantal gainful activity
--// as defined in IC 6-1.1-12-11(d)?
❑Yes I No ( / es ❑No
F3 the property used end occupied primarily for tsfbr residence? Doe,the applicants taxable gross income for the ug calendar year
exceed$17,000?
"Yes ❑No ❑Yeso
-
iadnp / !` ( Key member/Legal description Record number Page number
ll/�l� ��
4,C,-/S-79-/66'?-00/ D9SG CY1
I/We certify under penalty of perj't at the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the afoi- ICioned property on March 1, 20
Signature of applicant of applicant (number and street, state,and ZIP codeSignature de:( 7,>�---- F , �� if 39 5, /X- -fr5c St, �A-k M.0 4�/
signatu a of auttror¢ed YI Address of authorized re presentative (number end meet city,state,and ZIP code)