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•
ewe,. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
f, DEDUCTION FROM ASSESSED VALUATION
• stale Form 43710(R9/94E9
Prasmbed M Ne DeF*artmant d Loot Grnerturient Firunce
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). I e Mark
INSTRUCTIONS: DEC 27 2012
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:Outing the year for which the deduction is sought. c
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the a(12) Wore
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Name at applicant(weer or contract',aye,' {
`. : • 1 � `\
Is a•+u1-nt the sole legal or equitable owner? If No,what is hiv/er exact slave of irderest? If owned with someone other than spouse.
• indicate with whom:
VYes ❑No
tt name on record is different than that of applicant.indicate bebw:
Name of contract seder
Address of contract seller(number and street,dry,sate,and ZIP code) Is the property in question
❑ Real Property ❑ Annually Assessed
Mobile Horne(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 El No X, Yes No
la the property used and occupied primarily fir his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17.000?
❑Yes ❑Noes ❑No
Taxing district Key number I Legal desaiptien Record number Page number
a_k_c5e_Aus\ -IDS2p se) 1, -1l-�a -14) - ofla, tlg-ba
IiWe 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
red applicant Address of applicant (number and strecOsa te,and ZIP - `
ita Sip red authorized representative V Address of authorized representative (number and street,city,state.and ZIP code)