Disabilty_Miller APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
MIN
State Form 43710(R9/9-08)
Presuibed by the Department of Local Government Finance
®formation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File j ,�
INSTRUCTIONS: - -
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. APR 2 4 2015
2) Mobile Homes assessed under IC St 1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name cif applicant(owner o-`°" buyer) � ���� GIBSON COUNTY AUDITOR
oo n Lin
Is applicant the sole legal or equitable owner? 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 that of appliicant_indicate below:
Name of contract seller
Address of contract seller(number and street,city,slate,and ZIP code) Is the property in question:
[ateatPruperty ❑ Annually Assessed
Mobde Home(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 Efrlo 'es ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
1/4d yes 517.000?
(_J Yes ❑No ❑Yes 010
®Taxing dint Key number/Legal description Record number Page number
ofeni 2 tom_ /a - /05000 599 Dag" •
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 .
Signature of applicant /In Address of applicant (number and street,city,state,and ZIP code)
x/4-14,�' .y,, bQ iY1r.Pai Ass .(/, /IM) fide, irince"CeA f2- `y7G70
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)