Disabilty_Dewig a APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWN S HIP YEAR
t;" DEDUCTION FROM ASSESSED VALUATION
.`N
Pam State Fa 43710(R9 19fi6)
+ Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). F I a FJ an
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.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly4lil n4tl9 t (12)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 or contract buyer) •
�,t t / , 1 k�j , c((qq``�� GIBBON COUNTY AUDITOR
Is applicant the sole legal or equitable owner? I No,what is hisrher ex share of interest? If owned with someone other than spouse,
VVindicate with whom:
❑Yes ❑No
If name on record is different than that of apparent.indicate below.
Name of contract seller
Q`
Address of contract seller(nwrper and street,city,slate.and ZIP code) Is the property in question:
❑ Real Properly ❑ Annually Assessed
Mobile 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 Noes ❑No
Is the property used and occupied primarily for hismer residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
,Yes ❑No 14 Yes ❑No
Taxing district Key number I Legal description Record number Page number
k I gav- -CUO 276016
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 .
Signnatu of appellant � i/ (►,y� Address of applicant (minter ands street,/city,state,and ZIP code) / �/
�'C i" o(/—�op,V��� .r < w &g/ 4-7n TT /DYt /gene h l/F
Signature of authorzed representative v Address of authorized representative (number and street,city,state,and ZIP code)