Disabilty_Angle APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
ERI
State Form 43710(R9/g-0e)
Prescribed by the Department of local Government Finance
11 !
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). :III p.1
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. OCT 1 7 2017
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: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. T.H'1Trt
Name ofap (owner n-contract Mnye° GIBSON COUNTY AUDITOR
ts applicant the legal or equitable owner? ff No, is his/her exact share of interest? O owned with mlmane other than spouse,
indicate with whont
❑Yes ❑No
If name on record is different than that of applicant,indicate bettor
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP oath)) Is the property in question
❑ Reap Property ❑ Annually Assessed
Motile Hare(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 intul 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 ❑No
Taxing district Key number I Legal description Record number Page number
aG- \ 3 -t4 -c 0 9aO'DO1 -0cos
INVe 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)
0 3 L) &,a ao-e itrtAat 4764
£aSon0'
tative Ad ess of authorized representative (number and street,city,state,and ZIP code)