Disabilty_Whitaker 1. _.; APPLICATION FOR BLIND OR DISABLED PERSON'S (r�H!rW TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION c
Stascnbed 43710(epartm 8) OCj 1: 2 16
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). • </ ark
INSTRUCTIONS: ' AUDITOR
To be filed in person or by mail with the County Auditor of the county where the property is located. GIB$GN COUNTY A
Filing Dates: 1) Real Properly: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 Property:During the twelve(12)months before
March 31 of each year the individual wishes t obtain the deduction.
See reverse side for additional instructions and qualifications. �� �€ 8' -/5-R o/)
Name of applicant(owner or conba,.ctt bluyer)
Is applicant the sole I or equitable b eoowneR If No,whaler exact share 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 contract seller
Address of contract seller(number and sweet,city,state,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually 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)? n 0,
❑yes ❑No I 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? X�991t
Yes 0 N felYes 0 N
Taxing dist' Key number/Legal description Record number Page number
7,7 07h6.13-13-3001 02137 ez7L 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
Sign. '-of appfica / Address of applicant (number and street,city,stag,and ZIP reds)
,/
, I (Al PA . //O ?& E / s.2S gie War4 -riv a
`/76
Sig . ure of auth ed representative Address of authorized representative (number and street,city,state,and ZIP code)