Disabilty_Williams sT'"• APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
`t . DEDUCTION FROM ASSESSED VALUATION •
.:i.7.-.;;,...:. ' State Form 43710(R9/9-08)
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' � Prescribed by the Department of Loral Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-14-12-12(b). F limp
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INSTRUCTIONS:
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 r,"(� Q 2 n�7
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During e e l Ynonths before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. •
Name of applica or confect buyer]
GIBBON COUNTY AUDITOR
Is applicant the sole legal or equitable n . If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No •
It name on record is different than that of applicant,indicate below
Name of contract seller
Address of contract sever(number and street,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 substanf gainful 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$17,000?
❑Yes ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number Page number
a( -10{-bb- 403-Tay1-
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)
4at ±4tC4* f_t LR "°.`4 b " � 4 *1re of authorized repree Address of authorized representative (number and street,city,state,and ZIP code)