HomeMy WebLinkAboutDisabilty_Cain r APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOwNSNIP YEAR
fj , DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R9/9-08) ' A J F./Presamed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6x1.1-12-12(b). File Mark
INSTRUCTIONS: JUN 11 2013
To be filed in person or by mail w+th the County Audio,of the county where the property is located.
Fling 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 Properly: (12)months before
March31 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)
o6c2/„,4-.0-C Ca— j2'
Is applicant the sole legal or equitable owner? If No,what Is hislher exact sham of Interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
If name on record is d'dletent than that of applicant,Indicate belay.
•
Name of contract seller
Address of comrad seller(number and street,cry,state,and ZIP code) Is the property in question:
❑ Real Property ❑ AmuatlyA_ssessed
Mobile Hare(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)? am
❑Yes ❑No ,c rYes ❑No
Is the property used end occupied primarily for hisThar residence? Does the a ircoac4s taxable gross income for the preceding calendar year
exceed$1 1.000?
tgYes 0 N El Yes El No
Key number/Legal desaiatian Record number Page number
26 - - 07 -303 - 00 / •
4138-0}8
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
Signature of app kart Address of applicant (number and street,city,state,and ZIP code)
A S L ` ( e( /70 7 S. 1 l cl767)
Signature of authorized representative Address of authorized representative (number and sheet,dbt seats,and ZIP code)