HomeMy WebLinkAboutDisabilty_Fisher "'" APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
r - 1 DEDUCTION FROM ASSESSED VALUATION
Slate Farm 43710(R9/9-08) P 1
S' i !{E
'^�� Prescribed by the Department of Loral Govemmem Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(4 ti e a
INSTRUCTIONS: AUG 15 2016
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly:, months before
March 31 of each year the individual wishes to obtain the deduction. 17
See reverse side for additional instructions and�qualifications. G I B SO N COUNTY AUDITOR
Name of ape!' contract buyer)contract buyer) It V
Is applicant the sole legal or equitable owner? if No,what is his/her exact share of interest? If owned with someone other than spouse.
indicate with whom:
13 Yes 0 N
If name on record is different than that of applicant,indicate below.
Name of contract selle Q
Address of contract �er(number and sheet,city,state,and ZIP aide) Is the property in question:
O.Real Property ❑ Annually Assessed
Mobile Horne(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 .ti:1No Yes ID No
Is the property used and occupied primarity for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
,Yes ❑No ❑Yes 41‘lo
tr ct Key number/Legal description Record number Page number
A.1)Q4 fit CIA a C— I a--o7 V{23--003& a-ca
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)
�_ >25 Ss Se.✓il r4a a3
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)