Disabilty_Brandebourg APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION D_. State Form 43710(R9/408)
' '• Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: MAR 2 4 2015
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:Owing 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 Property:Doing th s before
March 31 of each year the individual wishes to obtain the deduction. GIBSON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of apprtca owner or contact buyer)
II\
Is applicant the sole legal or equitable owner? If No,what is share of interest? If owned with someone other than spouse,
indicate with whom:
es ❑No
If name on record is different than that of applicant indicate below:
Name of contrail seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually Assessed
Motile Kane(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 'nful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No es ❑No
Is the pwpeny used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
❑Yes ❑No ❑Yes o
Taxing district Key number/Legal desorption Record number Page number
ac,-o -qo- /o/- 003.7a)-01
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 applicant Address of applicant (number and street,city state,and ZIP code)
Z 715 Al srgrt. Ap 4C
pi4TOKn /w N7GG 4
attire o authorized representative Address of authorized representative (number and street,city,state,and ZIP code)