Disabilty_Roberts APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
j; DEDUCTION FROM ASSESSED VALUATION
_ ' Slate Form 43710(R9/9-08)
Prescribed by the Department of Local Government Finance -1� -
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). F ' { .017
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. C
Filing Dates: 1) Real Property:During the year for which the deduction is sought. IIUI b( 2 1 206
2) Mobile Homes assessed under IC St 1-7 or Manufactured Homes not assessed as Real Prop rl':uuring the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. 1
Named applicant(owner or contract buyer) GIBBON VOUNTY AUDITOR
Po
ts apprt am a so. legal or equitable owner? tl No,what is tdsTher exact share of interest? 7 owrred with son m: other Than spouse,
irWwnic withwhom:
es ❑No
If name on record is different than that of applicant.indicate below:
Name of contract seller
Address of conbad seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real Property ❑ MnuallyAssessed •
Motile 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 su al gainful activity
as defined in IC c-1.1-12-11(d)?
❑Yes ❑No Yes ❑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$17,000?
❑Yes ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number Page number
9 ,- 1 - 1g- I o 4-ooa. swo-am 6
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,state,and ZIP code)
W I & o 1�Y1 c� P .,ut (116 7a
thorized re- - - lathe Address of authorized representative (number and street,city,state,and ZIP code)