Disabilty_Mallory APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION Rem rm 43710(R9/9-08)
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Prescribed by the Department of Local Government Finance N
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). gp
INSTRUCTIONS: MAR 2 8 2017
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 Property ring th !1v months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Name of applicant(owner or contract ctact buyer)
Is applicant the sole legal or equitable owner? If No,what is der exact share of bn t? If owned with someone other than spouse,
indicate with whom:
es ❑No
If name on record is different than that of app&ant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the popery in question:
❑ Real Property ❑ Annually As Posed
Mobile Home(IC 6-1.1-7)
Is applicant bfind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantia inful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No 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 517,000?
❑Yes ❑No ❑Yes
Taxing district Key number/Legal desaiplion Record number Page number
96, - /k- /Y-10'-{- COO. cr3G€o7
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 ppfirant Address of applicant (number and street,city,stare,and ZIP code)
C- I as t,J litiLed CC-It if74 o
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n ure of authorized represenla. Address of authorized representative (number and street,city,state,and ZIP code)