HomeMy WebLinkAboutDisabilty_Dewig (4) _,r, APPLICATION FOR BLIND OR DISABLED PERSON'S coma? TOWNSHIP YEAR
D
EDUCTION FROM AS S ESSED VALUATION
State Form 43710(R919-06)
Presorted by the Department of Local Government Finance
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 min the CountyAudr#or of the county where the property is 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: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. FILED
Name of appliwm(owner or contract buyer) 4 /� j�/�� ,C63
3 g� ILED
Is applicant the sole legal or eQWt owner? If No,what is his/her exact share rarest? If owned witr a tarlp spouse.
"JJ indicate wtdrl�j�.
❑Yes
If name on record is different than that of applcant(indi ate below: `MR�,�^•'
GIBSON COUNTY AUDITOR
Name of contract se at
Address of contract ber and street city:state,and ZIP code) Is the property in Question
O PI y D AnnuallyAssessed
!viable Horde pC 6-1.1-7)
Is appdeal*blind as defined in IC 12-7.2.21(1)? Is appficant disabled and unable to engage In any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes fRNo E Yes ❑No
h the property used and occupied primarily for hasher residence? Does the applicants taxable gross income for the precedng calendar year
exceed 517,000?
FYes ❑No ❑Yes ISINo
Taxing district Key number I Legal description Record number Page number
c�
au CU— r�6— 8—3 -aoa --ova 2&O- -
l e 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
Signature of applicant Address of applicant (number and sheet dry,state,and ZIP code)
>C3 � 3o of authorized w • rn +street! n1,0146,474-leg/0 t 7X39