Disabilty_Tremps •
APPLICATION FOR BLIND OR DISABLED PERSON'S COUN 111_111bE [Il�� �
DEDUCTION FROM ASSESSED VALUATION �I i i j.j
State Farmby the (ep Department �..
Prescribed by the Department ol Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). r - Vire 1
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. R ��
Filing Dates: 1) Real Properly:During the year for which the deduction is sought. GIBSON CO/_UN7 T�YA
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(I riz)PgRefore
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)
& % Q//2 9 4
Is applicant the sole legal or equitable owner? If No,what is Maher exact s 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 centred seller
Address of centred seller(number and street,city,state,and ZIP code) Is thf property in question:
pQ Real Property ❑ Annually Assessed
Mobie Home(IC&-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 Q�Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income forth preceding calendar year
exceed 517,000?
❑Yes ❑No ❑Yes ❑No
C rill Key number I Legal description Record number Page number
uf�s>J�//� , d�/��a ��� c �3i-oat
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 .
Siggnnaa}ure of applicant Address
(� Address of applicant (number and street,city,state,and ZIP code) / 1 /
I` C�.Q , 7 /65 F (4 PKSr �r CNSVr �/t, /A✓ 7 I
Signature of aulhp ed representatf Address of authorized re sentative (number and start,city,state,and ZIP code)