Disabilty_Palmer ` APPLICATION FOR BLIND OR DISABLED PERSON'S . - COUNTY • -TOWNSHIP YEAR
`�'`'xt - DEDUCTION FROM ASSESSED VALUATION
, ,, +. State Form 43710(R12110-15) �•
�°+ Gibson Johnson 2017
Prescribed by the Department of Local Government Finance
pi Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
File Mark
INSTRUCTIONS: FILE
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:Form must be completed and signed by December 31 and filed or byr{t)e following January 5.
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2) Mobile Homes assessed under IC 6-t 1-7 or Manufactured Homes not assessed a p4ttj4 During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner r contract buyer) GIBS 0NCOUNTY-AUDITOR
Palmer, Theede Joni R.
Is apogean'the sole legal or equta!`owner? If No what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
El Yes 0 N
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,end ZIP code) Is the property in question:
0 Real Property ❑ Annually Assessed
Mobde Horne(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 slbstantial gainful activity
as defined in IC 5-1.1-12-11(d)?
❑Yes 01 No 0Yes 0 N
Is the property used and occupied prunardy for histher residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17.000?
Elves 0 N ❑Yes 0No
Taxin district Key number/Legal description Record number(contract) Page number(contract)
aG- 9 �s-yap go7. 7770�'�
1o�C J PT NE SE 15 4 10 2.30 AC D-9
e certify under penalty of perjury that the above and foregoing information is true and correct. `
Signature of appfcant i% Address of applicant (number and street,city,state,and ZIP code)
�.,./ c . „: "Xl2 ligle& 12693 S 350 E Haubstadt, IN 47639
Si a of authorized representative f Address of authorized representative (number and street,city,state,and ZIP code)
0.72.f�' Id. . ..-..
L369-acs? doS9