Disabilty_Livermore Cat 0a
i-`� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
,. i _ DEDUCTION FROM ASSESSED VALUATION
` Slate Form 43710(R7/5-06) n\\O /
Prescribed by the Department of Local Government Finance \"Jt`
Information contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n)and IC 6-1.1-12-12( ). II'm '
NSTRUCTIONS: R
To be filed in person or by mail with the County Auditor of the county where the property is located. ! 7 '
Filing Dates: 1)Real Property:During the 12 months before June 11 of the year the deduction is to bfl Wfe ive.
2)Mobile Homes assessed under IC 6-1.1-7:During the 12 months before March 2 oPt�bM}4aritl 9ividual wishes to
obtain the deduction.
See reverse side for additional instructions and qualifications. .,: ex
Name of applicant(owner or contract buyer)
13ob 2 f `Z �: GIBBON COUNTY AUDITOR
Is applicant the sole legal o equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
❑Yes ❑No
If name on record is different than that of applicant,indicate hetnn,
Name\ofyf ccoonnttr ct ssllell`er --
Address of con act seller Is the property in question:
❑Real Property ❑ Mobile Home(IC 6-t1-7)
Is applicant blind as defined in IC 12-1-1-1(n)and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ftyNo ''es ❑No
Is the property used and occupied primarily for his/
Yes
ng ' trict n Key number/Legal description 'Record number Pa number
�0. Y -
IANe 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 r Address of authorized representative