Disabilty_Perry ij-iC :� State ``
YEAR
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YR
DEDUCTION FROM ASSESSED VALUATION Sta Form 43710(R9/9.08) `t��
Prescribed by the Dep rbnent of Local Govermnent Finance ct6A�
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). FILED
L, 5..ya�
rgTRUCTIONS: {1� 1 �� J1
bled in person or by mall with the CountyAuditor of the county where the property Ls located.
Dates 1) Real Property:During the year for which the deduction is sought II''r(� nf1 99 n�����
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:bMMg`Cr�ti4aW1(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
litlfrilfkir
Name of applicant(owner or contract
p_ C^ A� 6b0,4:, GIBSON COUNTY AUDITOR
Is applicant the sole lei or equitable owner? ' // If Nlo. wwhat. is his/her exact share of If owned with someone other than spouse.
indicate with whom:
❑Yes 0 N
If name on record is different than that of apply bndicate below.
Name of contract seller
Address of contract seller r a�t,dry,state,and ZIP code) Is the property in question:
❑ RS Property ❑ AnnuallyAssessed
Mobile Hare pC 61.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 61.1-12-11(d)?
❑Yes o Cayes ❑No
pr
Is the property used end occupied primarily for residence? Does the applicants taxable gross income for the preceding calendar year
exceed 517,000?
121Yes ❑No ❑Yes rgNo
edisCoAL4k, Key number I Legal description Record number Page number
Me 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 of Address of applicant (number and street,cal:state,and ZIP cede)
"` ,l t.1, g � x-Pa , 1/2 jiw„(.. ,�D y7av�pl aWnraed representative Address of authorized representative/(number and soee4 thy state,and ZIP code)