Disabilty_Ambrose °-,* APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR, ,
- i- DEDUCTION FROM ASSESSED VALUATION xlllttt
S'..-...;'.:-_,,_:-.• State Forth 43710(R12/10-16) I
5 =� Prescnbed by the Department of Loral Government Finance`.
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. e Mark
INSTRUCTIONS: MAY 4 2018
To be filed in person or by mail with the County Auditor of the'county where the property is boated.
Filing Dates: 1) Real Property.Form must be completed and signed by December 31 and filed or poslm. • ed by the folio hg J. vary 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as R.;FN.:-.?y d. the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction. di.
GIBBON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
Is appfuant the sole legal or equitable own a Li If No,what is hL4her exact share of interest? • owned with someone other than spouse,
indicate with who=
❑Yes ❑No
If name on record is different than that of applicant,indicate below
Name of contrail seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in quesson:
ikiteal Property ❑ Annuallypssessed
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 9011go (�'es ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the •ing calendar year
exceed$17,000?
❑No ❑Yes ?o
7 dis Key number 1 Legal description Record number(contract) P ge number(contract)
/20riO. Z4-la -/Fl- 203- ooa .670 -02- if
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
tore o p t Address of applicant (number and street,city,state,and ZIP code) fJ,P,,vo E reN
/1/8 s t s r r v X7,0 7a
Si nature of authored rep ' e of author zed representative (number and street,city.state,and ZIP code)
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