Disabilty_Hale APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY I TOW NSHIP YEAR
1� DEDUCTION FROM ASSESSED VALUATION ggg
1 Slate Farm 43710 epa 9-08) p i
Prescribed by the Department of Local Government Finance 1 �.�
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File 'a '�
INSTRUCTIONS:
DEC 22'2014
To be filed in person or by mail 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.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly) - �ths before
March 31 of each year the individual wishes to obtain the deduction. GIBBON COUNTY
See reverse side for additional instructions and qualifications. AUDITOR
Name of applicant or contract buyers 4
owner?Is applicant the sole legal or equitable wneerr?I If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
Yes ❑No •
If name on record is different than at of applicant,indicate below.
Name�o`/(1/mrpratl seller
`
Address contract seller(number and street,dry,slate,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually Assessed
Mobile Bane(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 No 51 Yes ❑No
Is he property used and occupied primarity for is/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed S17,000?
MYes ❑No ❑Yes IKI No
Taxing ustrict Key number I Legal descripllon I Record number Page number
a.f a_ are-�a is acn -003 7W-102
7
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 appGgm Address of applicant (number and street dty,scam,and ZIP code)
, �,,,l cod.
U�iu)y., _fr1_.` 1 ' 909 S . ,Oo5v good(iv pr^,'r✓cre FA) "1x7670
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)