Disabilty_Hill APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
,., DEDUCTION FROM ASSESSED VALUATION
•� State rb 43710(R9/9-08)
Pres cribed by the Department of Local Government Finance LT
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). 9 File Math
INSTRUCTIONS: NOV 9 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 Properly:During the year for which the deduction is sought. f)�
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Prop edYl[7u' e(12)months before
March 31 of each year the individual wishes to obtain the deduction. GIBSON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of nt(owner or contract buys Gin:/ �/
I/KQJ �Jl 1 Y !/
Is applicant the sole legal or equitable owner? If No,what is hisdter exact share of interest? If owned with someone other than spouse,
�,.( indicate with whom:
I�{,Yes ❑No
If name on record is different than that of applicant,indicate below-.
Name of contract setter
Address of contrail seller(number and street,ciy,state,and ZIP code) Is property in question
Real Property ❑ Annually Assessed
Motile Home(IC 6-L1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substant ial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No Dyes ❑No
Is the properly 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
Taxi strict Key number/Legal description Record number Page number
Lrc�,eh , oTd -/0?/3 --CCOO 00v. 6,'/-/- 0017
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)
Oz°.e4zet y. 9808 E . 5 (dy FcQ.ic.scc Zed 914`11
rt•a- t
ignature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)