Disabilty_Nelson 4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
;; DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R9/9-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). . le :pi
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. MAR 2 7 2017
Filing Dates: 1) Real Property:During the year for which the deduction is sought. Li I
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 to obtain the deduction. )(litiva----
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer) G I BSON COUNTY AUDITOR
Is applicant the sole legal or equitable owner? N�/ exact share of int with someone other than spouse,
indicate with whom:
S ❑No
If name on record is different than that of applicant indicate below
Name of contract seller
Address of contras seller(number and street,city,state,and ZIP code) Is the property in question
❑ Real Property ❑ MnuallyAssessed
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 ❑No 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 ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number Page number
a - axe?-loq-c a hill iar
IIWe 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 of applicant (number and street,city,state,and ZIP���, applicant N � Titton co6
/�VA''at re of aulhar¢ed rep sentalive Address of authorized representative (number and street,city,slate,and ZIP code)