Disabilty_Ross -
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP •YEAR
ii
f; DEDUCTION FROM ASSESSED VALUATION
Stale Farts 43710(R919-08)
Prescribed by the Department of Local Government Finance
Information contained in this doament is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
To be filed INSTRUCTIONS:person or by mail with the County Auditor of the county where the property is located. FILE
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:Q gigg tfp twe�[12)months before
March 31 of each year the individual wishes to obtain the deduction. (J r.U l
See reverse side for additional instructions and qualifications.
Name of appOcanl(owner ar
//jot /� �12 �
L/l////////!I /��� GIBSON COUNTY AUDITOR
•
Is applicant the sole legal or equitable owner'? It No,what is hisher 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 below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
Prupe rly ❑ Annually Assessed
Mode 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 substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes 4o [ 'es ❑No
•
Is the property used and occupied primarily for his/her residence? Dces the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
(Yes ❑No ❑Yes ❑No
Taxing dis Key number/Legal description Record number Page number
e 4 ./G ig1y--�of� � 7
I/We certify under penalty of perjur 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 sheet,city,state,and ZIP code)
is (/ __ I Y y%/ Aar nil CM cftco/v s r onavg Cv7y4iv YYYEo
Signafu of oath -•re' a Address of authorized representative (number and street,city,state,and ZIP code)
