Disabilty_Lasley (4) Nf =F�, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
--1'' DEDUCTION FROM ASSESSED VALUATION
Ads State Form 43710(R919-06)
Prescibed by the Department of Local Government Finance
FILE
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(4
INSTRUCTIONS: NOV 7 2013
b be filed in person or by mad with the County AudIYor of the county where the property is located.
Ring Dates- 1) Real Property.During the year for which the deduction is sought ''/n1�'
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:Duppgthe s before
March 31 of each year the individual wishes to obtain the deduction. I t.nttzzn.
GIBSON COUNTY AUDITOR
See reverse side for additional instructions and qualifications. i
Name of..,,..,; • .r or contract buyer) `��/��/-
Is applicant. , or eq I.e If No, exact sham __ . If owned wi h someone other than sparse,
indicate with whom:
El yes 0 N
If name on record is different than that of applicant indicate below
Address of contact seller(number and ,state,and ZIP code) Is property in questiacr
Rell y ❑ AnnuallyAssessed
dale Home(IC 61.1-7)
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 0 N 1 ❑Yes El No
Is the property used and occupied primer y for histher residence? Does the applicants taxable grins Moony for the preceding calendar year
exceed$17,000?
es 0 N El Yes El No
Taring ( Key number I Legal descry ton Read number Page nun ter
Of 17.66 —i3—,cam4A6d
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
Signature of applicant Address of applicant (number and street,city,state,and ZIP bode)
i • ,, il
Sigratu e nt autnariud _. u.:.. Address of authorized representative (number and Meet, .state,and ZIP code)