Disabilty_Stephens APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
t, DEDUCTION FROM ASSESSED VALUATION ggg yyy
Slate Form 43710(R9/408) J
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: S E P 1 1 2 015
To be filed in person or by mail with The CountyAuditor 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 Property: 2)months 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 applicant(owner or contract buyer) `
Is applicant sole or equitable ownen�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 applicant,indicate below:
Name of contrail seller
Address of contact seller(number and street,dry,slate,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually Assessed
Mobile Hone(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)?
Dyes 0 N CO Yes 0 N
Is the property used and occupied primarily for hisher residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
/"Yes ❑No ❑yes ❑No
Taxing district Key number/Legal description Record number Page number
1 K a a6 -13- ao -I DI -pool, ors
IfWe 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 appfoant Address of applicant (number and sheet,city,state,and ZIP code)
141 1 ...p a_ �, x.30 4 L Vile ij- ncaw. c e .c. r • t-/7 G �) Cc
Signature of authat� re p en.
ntaltve Address of author iced representative (number and street,city,state,and ZIP code)