Disabilty_Richardson (4) r1 ~ r. APPLICATION FOR BLIND OR DISABLED PERSON'S =„ !_ Sri ' IP YEAR
�,'.-� '' DEDUCTION FROM ASSESSED VALUATION `, 1 W
State Form 43710(R9 19-08) •
Pre=med by the Department of Local covenanem Finance MAY 9' .113
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: �,�
To be filed in person or by mall with the CountyAuditor of the county where the property is located. /' J 1€�p"'*'�-"q�D%TOR
Filing Dates: 1) Real Property.During the year for which the deduction is sought. GIBBON COUNTY
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property During the twelve(12)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(owner or uyerl r )
Is applicant die sole legal or equitable owner? If No,what is his/her exact share of Interest? If owned with someone other than spouse,
Indicate with Worn:
Qaes ❑No
It name on record Is different than that of applicant indicate below:
Name of contract seller
Address of contact seller(number and street clot state,and ZIP code) Is the property in question:
Ce Real Property 0 AnnuatlyAssessed
Mobile Home(IC 6.1.1-7)
Is applicant blind as defined in IC 12.7-2.21(1)? Is applicant disabled and unable to engage in any substantial gainful acbvty
as defined In IC 6-1.1-12-11(d)?
El Yes (]No &lYes ID No
Is the property used end occupied primet9y for hiamer residence? Does the applicants taxable gross income for the preceding calendar year
exceed 817,000?
0 N lo Yes 0 N
Taring district
I/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 aforementioned property on March 1, 20 .
Sign applicant Address of applicant (number end sleet cdy,state,and ZIP code)
_.� LA A- .2 --Q• �Wt,fS0r)1C a V 2 6 4 5-
Sgnabue of authorized iepresentive ' Address of authorized representative (number and street city,state,aid ZIP code)
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