Disabilty_Beach j4.? APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
.. ;;_ DEDUCTION FROM ASSESSED VALUATION
Slate Form 43710(R919-08)
�"-- Prescribed by the Department of Local Government Finance 1
- r
Information contained in this document is CONFIDENTIAL pursuant to IC 61.1-12-12(b). 7, , ...•
INSTRUCTIONS:
To be filed in person or by mail with the CounlyAuditor of the county where the property is located. NOV fi - 2016
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 Property:During tl)Qjwewe(1 )coo the before
March 31 of each year the individual wishes to obtain the deduction. 1J�/Lf
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOh q
Name Saber�rd./�/wn/-�or or co conttact�buyyeer)0 (7id
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:
)1Yes ❑No
If 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 th property in question:
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant bend as defined in IC 12-7-2-2111)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes tic4o ''Yes ❑No
Is the property used and occupied primarily for higher residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
i.Zfes ❑No ❑YesNo
(in dUk y��Key number/Legal lddescription, I
Record number Page number
)2 At c7.to_is a7 7. ao. oo v7� 6.Iy116
I1We 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)
✓%}2 del (1 )( m03 SOLO'k cr J T 2 Si. FeT 6QA&e-P riv `f ' G y5i
Signature of authorized representative Address of authorized representative (number and street city,state,and ZIP code)