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r s^ APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
G% DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R9/s-08)
Prescribed by the Department of Local Government Fnartce
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS:
FILED
To be Wed in person or by mad with the County Auditor of the county where the property is located.
Ring Dates: 1) Real Property:During the year for which the deduction is sought
2) Mobile Homes assessed under 1C 6-1.1-7 or Manufactured Homes not assessed as Real Properly:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction. 2 5 2014
See reverse side for additional instructions and qualifications.
Name of applkaM fawner or contract co
r`lt(\If ) GIBSONCOUNTY AUDITOR
Is applicant 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 whom:
1�Yes O No
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:
E;st Real Pmperty 0 Annually A
Mobile Horne pC 61.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is 1-ndd-uty�to engage in any substantial gainful windy
as defined'
0 Yes 0 No /Yes 0 No
Is the property used and occupied primeniy for hisRbr residence? Does the appl cant's taxable gross income for the preceding calendar year
exceed$17,000?
Yes No El Yes No
Taring district Key number I Legal description Record number Page number
Pal in 04.41, Zlo- fa -,poi-6o0 a3 -02 �
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 applicant Address of applicant (number and street city,state,and ZIP code)
7 111- g�� dr
_ �` /h a w. l zra ha�.7�� 7 6 4- 'f 76 7o
Signature of authorized representative Address of authorized representative (number and street city ate,and ZIP code)