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Disabilty_Beck ;. 4, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR ,!!}�� ��„ DEDUCTION FROM ASSESSED VALUATION State Forni 43710(R9/9-08) Prescribed by the Department of Local Cw.emment Finance Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark INSTRUCTIONS: FILED T be tiled in peon or by mad with the County Auditor of the county where the property is located. Filing Dates.' 1) Real Property:During the year for whit the deduction is sought_ 2) Mobile Homes assessed under IC 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. 1)C T 8 2014 See reverse side for additional instructions and qualifications. Name of applicant(owner or covtract buyer) l//N/) tAk-�\`� ;1Xn-€ir/C/. GIBSON COUNTY AUDITOR Is applicant the sole legal or equitable owner? If No,what is hislher exact share of interest? If owned with someone other than spouse, indicate with whom: ❑Yes No If name on record Is different than that of appliient.indicate below Name of contract se9ar Address of contract setter(number and street city,state,and ZIP code) Is the property in question: ❑ Real Property ❑ Annually Assessed Motile Home(IC 8.1.1-7) Is applicant Sled as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substardtal gainful activity as defined In IC 6-1.1-12.11(0)? ❑Yes 15-41 No 114 Yes 0 N Is the property used and occupied primarily for hailer residence? Does the applicant's taxable gross income for the preceding calendar year exceed$17,01)0? Opp ❑No ❑Yes Nap to Taxing Key number/Legal desaiption Record number Page number cz/aa a -ld-03 - goac9a. -oar 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 Signatuzer;utpricant Address of applicant (number and street,say,state,and ZIP code) I70 E SO N rqce+ore l I t . /4 7670 signatue of emhor¢td representative Address of authorized representative (number and street,city,state,end ZIP code)