Disabilty_Holzmeyer . APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
-:s DEDUCTION FROM ASSESSED VALUATION tleF
Prate ribed by the (1e9 Department I 112 I�
Prescribed by the Depadment of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: NOV 2 9 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. /1
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Prop ' ve(12)months before
March 31 of each year the individual wishes to obtain the deduction. �lpWl
See reverse side for additional instructions and qualifications. GIBBON COUNTY AUDITOR
Name of applicant por contract buyer) IA
Is applicant the sole legal or egul.a owner? If No,what is hisrh tact share a erect? If owned with someone other than spouse,
,,��,,�� indicate with whom:
Yes ❑No
If name on record is different than that of applicant,indicate below.
Name of contract seller
Address of contract seller(number and street,city,slate,and ZIP code) Is the rty in question:
eal Property ❑ Mnualy 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 substantial gainful activity
as defined in IC 6-11-12-11(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/Legal description Record number Page number
a - is- 16 - ID o -OD or4i6-0:15
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) 51 7‘)/g
. 44rlure ot a •-. Address of authored representative (number and t,city,state,and ZIP code)