Disabilty_Leech .., + APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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t; DEDUCTION FROM ASSESSED VALUATION
State roan 43710(R9/9-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 61.1-12-12(b). Wgn de M
INSTRUCTIONS: A I
To be filed in person or by mail with the County Auditor of the county where the properly is located. .•
Filing Dates: 1) Real Property:During the year for which the deduction is sought. �P NI 1 4 9111 ( )
2) Mobile Homes assessed under IC 61.1-7 or Manufactured Homes not assessed as Real a OL Bid* a(12)months before
March 31 of each year the individual wishes to obtain the deduction. i
See reverse side for additional instructions and qualifications. a i
Name of applicant towrier/rcy�(�hact buy e"Q�� �� . W1N--iir
GI: .n :�'•�'i� AUDITOR
GIBSON COUNTY AUDITOR
Is applicant the sole legal or equitable owner? If No,what is his/her exact sham of interest? If owned with someone other than spouse,
indicate with whom:
Yes ❑No
If name on record is different than t}iat of applicant,indicate bebw:
Name of contract seller
M iCL,
Address of contract seller(number and street,city,stab,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 61.1-7)
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 eg,No )C]Yes 0 N
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?
Yes ❑No El yes �No
Tbict
IIVVe 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 ) �71 %'�a//� Address 49 off applicant (number and street,city,state,and ZIP�codddee).
a/00 fr/f lr�/' /µl " 0- 4/la V cv , !/ 0 —
nature of authcnsed representative Address of authorized representative (number and street city, to and ZIP code)