HomeMy WebLinkAboutDisabilty_Sprinkle '._ APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
Preto Form (R9/9-08)
Prescribed by Ithe Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). Fil' r:.'
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 Properly:During the year for which the deduction is sought JAN 4 2016
2) Mobile Homes assessed under IC 6-1.1-7 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. /)r ,
See reverse side for additional instructions and qualifications. •Nyl '
Name of applicant(owner or contract buyer) A �i GIBSON COB TY AUDITUN
Sh A e /,q 3 rJN /\ I €
Is applicant the sole legal or equitable owner? If No, is hisrher 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 belay:
Name of attract seller
Address of contact seller(number and street,city,state,and ZIP code) }}I��s n
..��the property in question:
tr�ll Real Rupaty ❑ AnnuailyPssessed
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 ❑No ❑Yes El No.
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
PYes ❑No ❑yes gl No
Taxing district Key number/Legal description Record number Page number
l fan n-ia-/Ss-/o i CO 7a 80 8
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,stain,and ZIP code)
�5/.(A i� 611A i riCG ( e 8O 6 /ADA- Yoh Jit c_i- (-vt , III . ` 1 1O
Signature of authorized rep esentative Address of authorized representative (number and street.city,state,and ZIP code)