Disabilty_Phillips ' APPLICATION FOR BLIND OR DISABLED PERSON'S cou
DEDUCTION FROM ASSESSED VALUATION
Man ,
�, Slate Form 43710 Department 6)
Prescribed by the Department of Local Goxemment Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). I e -
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
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Filing Dates: 1) Real Properly:During the year for which the deduction is sought. G I BSO N COUNTY r` '�'�^AUDITOR�
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months-nefore
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of ap (owner or contract buyer)
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Is appr t e sole legal or equitable owner? If No, .t is histher exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
It name on record is different than that of applicant,indicate below-.
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is property in question:
Real Property ❑ Annualty Assessed
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 o 9 es ❑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?
Yes El No ❑Yes-1 No
p strict Key number I Legal description Record number Page number
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UWe 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 sheer,city,state,and ZIP code)
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Suture of authorized epresentatNe Address f a thorized representative (number and street,city,state,and ZIP code)
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