HomeMy WebLinkAboutDisabilty_Simms 411et _;�, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
;,,, COUNTY DEDUCTION FROM ASSESSED VALUAT4t DULY ENTErcED tux IAXAI ION
State Form 43710(R9/9-06) ( 11 L IF D Subject to filet acceptance 'or transfer
Presatbed by the DepaNnent of Local Government Finance j . day o
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-I2-12(b). n File Mark •
INSTRUCTIONS: MAY 1 2013 Y Auditor
b be filed in person or by mall with the County Auditor of the county where the • •perty is located. Gibson County
Filing Dates 1) Real Property:During the year for which the deduction is -11 '_ ./ Parcel #
2) Mobile Homes assessed under IC 6-1.1-7 or Man --Sr �r.) e+i.fTl!r..-=d as Real Properly:Dung the twelve(7 Z)mans befura
March 31 of each year the individual wishes to obtat i~_!-. . a ,NTY AUDITOR
See reverse side for additional instructions and qualifications. .
Name of applicant(owner or contract buyer)
(6� i / `
Is applicant n -..: If No.what Is his/her exact share of interest? If owned with someone other then spouse,
indicate with whom:
• Yes ❑No
If name on record Is different than that of applicant indicate below:
Name of contract seller
Address of contract seller(number and street,ct0:state,and ZIP code) Is the property in question:
❑ RS Property ❑ AnnualyAssessed
Mabee Horrle QC 6-11-7)
Is applicant brad as defined in IC 12-7-2.21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes 0 N El yes 1-0-No
is the property used and occupied primarily for hisAter residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes 121 No
Qtdistrict - /_
1/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforem- boned property on March 1, 20
Signabaa
//
of: t • /,. Address of authorized representative 1 rand street,aly te.and ZIP code)