HomeMy WebLinkAboutDisabilty_Hulen . APPLICATION FOR BLIND R DISABLED_PERSON'S COUNTY TOWNSHIP YEAR
�•;- DEDUCTION FROM ASSESED VALUATION
p' '-R State Form 43710(e12 t 10.16) ! �(' 1 �
'-�,� T Presrnbed by the Department of Local Government Finance ®tl
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. I -
INSTRUCTIONS: DEC 2 7 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:Form must be completed and signed by December 31 and filed or postmarked by theufollowing January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property{Mi J1i2fmonths before
March 31 of each year the individual wishes to obtain the deduction. GIBBON COUNTY 4
See reverse side for additional instructions and qualifications. UD ITOR
Name of applicant owner or contract buyer)
AS
et
jai, F
Is applicant the sole legal or equitable owner? If No, t 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 below
Name of contract seller
Address of contract seller(number and street,city,state.and ZIP axle) Is the property in question:
Real Property ❑ AnnuallWAssessed
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 6-1.1-12-11(d)?
❑Yes II-No Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
.Yes 0 N >Q Yes CI No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
W? 97rn r 7 /n-/ -O $ ail 3 cC 19 5 a o a sc
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
•
/`a, / ,• /6co 6YYi-,2oc/gig(/
Signature of authorized representative Address of authorized representative (n berand street,city,state,and ZIP code)
•
.
1