HomeMy WebLinkAboutDisabilty_Chamberlain (2) .r:%r,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
^^_' DEDUCTION FROM ASSESSED VALUATION
FI E
State Fenn 43710(R9/408)
Prescribed by the DepaNrent of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
•
INSTRUCTIONS: JUN 5 2013
To be filed in person or by mail with the County Audior of the county where the property is located.
Filing Oates 1) Real Property.Owing 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 P (12)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) 1
Is epee t the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
Indicate with wizen:
Dyes 0 N
If name on record Is different than that of applicant indicate below
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real q ty 0 AnnuallyAssessed
It Home(IC 6.11-7)
Is applicant blind as defined In IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantal gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes 5/No ❑Yes ❑No
Is the property used and occupied pritrergy for hisfror residence? exceed$Doe,the 177,0 appf00?ranrs taxable gross income for the preceding calendar year
iv Yes 0 N El yes 0 N
district Key number/Legal desaiptton Record number Page number
a-eo einj ,-eu14—) '26 -6"/-.141. 303 _o00. 44167-0,10
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 .
y Signature of applicant of applicant (number and sheer,sty,state,and ZIP code)
1 C��f�x.Y 09// /I/• 0 A7[Q a y GA.n 2 ?Arc K� r.,- 4474 64
of authorized representative Address of authorized representative (number and street,dry,state,and ZIP code)