Disabilty_Townsend ititi.c-4, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
rf DEDUCTION FROM ASSESSED VALUATION
:" state Form 43110(R9 19-08)
Prescribed by the Deparbnent of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: FILED
b be filed in person or by mall with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property.Owing the year for whit the deduction is sought -
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly:DuriptittRe tivegfig months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(mvneror contract buyer)
((\\7�y���`Q�y��y� n.CrtinLQ9,K.01 GIBSON COUNTY AUDITOR
Is applicant the sole legal or equitable owner If No,what is blether exact share of interest? If owned with someone other than spouse,
indicate with whom:
Yes ❑No
If name on read is different than that of applicant indicate below
Name of contract setter
Address of contract seller(number and street,c101 state,and ZIP code) Is the property in question
0 Real Property 0 ArnuarlyAssessed
Mottle bonne QC 6-11-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any subsfantai adivty
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No as 0 N
is the property used end occupied primar3y for It/her residence? Does the I's taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes No ❑yes LTNo
Taxing district Key number I Legal description Record number Page number
a( - ii-la - Loo -caotes-027
UWe 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 aforementioned property on March 1,20
signaMe ..� Address of applicant (number and street,city,slate,and ZIP code)
orh",g,..-repr,21,C41,ad 7<f457 fipl-e4 Acide, fe7e?a
Address of authorized .rw,: bve (number and itreet,cry state,and ZIP code)