HomeMy WebLinkAboutDisabilty_Hammel gltAPPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY I TOWNSHIP YEAR
tDEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
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: D
To be filed in person or by mail with the County Auditor of the county where the property is located. �,/
Ring Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the -r anuary 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly:During the tweye.121jcnths before
March 31 of each year the individual wishes to obtain the deduction. MAY 11 11 LL
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
AL� Al Al / GIBBON COUNTY AUDITOR Lin
Is applicant the sole legal or equitable owner? If No,what is Ns/her exact share of Interest? If owned with someone other than sparse,
, indicate with whom
❑Yes 0 N
If name on record is different than that of applicant,indicate below.
I Name of contract seller
Address of contract seller(number and sheet,city,state,and ZIP code) Is the property in question:
CSaalProperty ❑ Annually Assessed
Mobile Home(IC 6.1.1-7)
Is applicant blind as defined In IC 12.7.2-21(1)?
Taxing district Key number/Legal description Record number(contract) Page number(contact)
O aa to-/4 -/8 - X09 -cc / .037-007
I/We certify under penalty perjury that the above and foregoing information is true and correct.
Signature offaa nt Address of applicant (number and street,city,state,and ZIP code) / �--
/s at /�L 1.1 5a 7 Vcti-c 5&aept 0 aJd4no( .
g hi of authorized representative Address of authorized representative (number and street,dt7,state,and ZIP code)
7 CeC4o