HomeMy WebLinkAboutDisabilty_Basham 4:-=t, APPLICATION FOR BLIND OR DISABLED PERSON'S Coup T T Yee
�+ 41 DEDUCTION FROM ASSESSED VALUATION �`
State Form 43710(R9/sae)
'1+"� Prescribed by the Department of La:al Government Fnance �r,
FED Fae`Mh11(14
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
INSTRUCTIONS: ntPP��+ �
To be filed in person or by mail with the CountyAudrtor of the county where the property is boated. GIBSO`N'iCOUNTYAUD17-
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.
Name of a t(owner or contract buyer)
(o�orcoQi y //
Q
Is applicant the sole legal or equitable owner? If No,what is Mather exact share of interest? if owned with someone other than spouse,
indicate with vAran:
Yes ❑No
If name on record is different than of applicant,Indicate below:
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is property in question:
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
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 6-1.1-12-11(d)?
❑yes ' o ❑Yes ❑No
Is the property used and occupied per'for hisTer residence? Does the applicants taxable gross income for the preceding calendar year
�( exceed St 7,000?
Yes CI No ❑Yes 0 N
Tip d q /-/
1$Yes
number I Legal description Record number Page number
1We 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, ZIP
/ e f_ ��Mr, pro °3 S --77-e- ektat-
Signabe/' of authorized representative Address of authorized representative (number and street city,state,and 2113 code)