Disabilty_Smith rex_.rr, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R9/9.08)
Presamed by the Department of Local Goverment Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). T L
INSTRUCTIONS: 1 E
To be filed in person or by mall with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought. II
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Proper Bur tl2 lve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. n/ - ,¢�
Name of or contract buyer) GIBSON COUNTY AUDITOR
nip I
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,
fndimte with whom:
es ❑No
I1 name on record Is different than that of applicant indicate belcw:
Name of contract seller
Address of contract setter(number and street city state,and ZIP code) Is the property in quest
❑ Real Property 0 AnnuallyAssessed
Mollie Home(IC 6-1.1-7)
Is applicant brad as defined N IC 12-7-2-21(1)? I Is M 1andd-unabe to engage in any ac4`^ty
❑Yes ❑No es ❑No
Is the property used end occupied hisfrer residence? Dees the t is taxable woes income for the preceding calendar year
exceed$1 ,000?
Yes ❑No ❑Yes o
Taxing district Key number!Legal desotption Record number Page number
061.3-1a-3co - -ahs 0910
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 sheet city,stale.and ZIP axle)
Y4/41:rjd
xilacQ- s/Feee) a"Pe' .v.° eiV .1,-cJ y7lo6?
o ized representative Address of authorized representative (number and street city gate,end ZIP code)