Disabilty_Nelson APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
i? DEDUCTION FROM ASSESSED VALUATION ---
State Form 63710 ep rtmen
Prescribed by the Department of local Government Finance yyy
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). - File
INSTRUCTIONS: 4'
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 A�1p po cc �rr11
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:OUhIIg Me twit Ihl 2)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer) G I BSON
�A a—\, COUNTY AUDITOR
Is applicant the sole legal or unable owner If No what is his her exact share of interest? If owned with someone other than spouse,
indicate with whom:
I7Yes ❑No
It name on record is different than that of applicant indicate below:
Name of ccoritrar seller
CL
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
ICI.Real Property 0 Annually Assessed
`77`` Mobile Bane(IC 6-1.1-7)
Is applicant bind 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 LaiNo >:0 Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
F6Yes S17,000? rr���'
Yes ❑No ❑Yes ,YS Io
district (( Key number/Legal description Record number Page number
'r)t a(0- 3-:a- 3ca-ocd.Q01/41--
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 n ,, Address of applicant (number and street,city,state,and ZIP code)
z i/lea .-.--• � )0 7 9 t E . S c S , Oar Idct rid C t1f`� y 7 (; 6 0
Sign leetnns-
ure of authorized representative Address of authorized representative (number and street,city,state,and ZIP )