Disabilty_Doughty '°' APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
i t�' DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10.16)
t:' 'j Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS: APR 6 18
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Pmperty:Form must be completed and signed by December 31 and filed or postmarked by the f wing J aua2:1
2) Mobile Homes assessed under IC 61.1-7 or Manufactured Homes not assessed as Realpr��fty t 2)months before
March 31 of each year the individual wishes to obtain the deduction. �IBSON COIJN7Y DlT'QR
See reverse side for additional instructions and qualifications.
Name of as scant(owner orr r//tract b ee/r),,
Is a t the sole legal or equitable owner? / If No, t is his/her exact shah:of interest? If owned with someone other than spouse,
indicate with wit=
❑Yes 0 N
If name on record is different than that of applicant,indicate below.
Name cot seri /J „Li2„/„..„
Address of contract seater(number and . ,state,and ZIP code) Ism `Operty in ques5on:
1sReal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is app leant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes 0 N ❑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?
y'es ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contact)
.A LisAisi, is/7/J/- 000 4/0 -0AA
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
/� Address of applicant (number and street,city,state,and ZIP code)
l/�I�, �- �4( X / -t1 I - _ 0. 062
lar".lure of authorized rep -- •- ' e Address of authorized repre -ntative (number and street,city,state,and ZIP code)