Disabilty_Larson APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
;. DEDUCTION FROM ASSESSED VALUATION
3 t"=- " State Form 43710(R12/10-16)
S` J Pnsaibed 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: JUL 3 2018
To be filed in person or by mail with the County Auditor of the county where the property is located.
Fdmg Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the followir Janua !'5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During l M . Ms before
March 31 of each year the individual wishes to obtain the deduction.
reverse side for additional instructions and qualifications. GIBSON COU�!TY to.iDiTOR
Name of applicant(owner or contract buyer)
C‘cN■VChPJ\ \s.:\\ \l t. t11 A- I L)sgcIt
L9'Yes ❑No
If name on record is different than that of applicant,indicate below-
•
Name of contract sew
Address of contract seller(number and street,city,state,and ZIP code) Is�tthee„weeny in question:
[P teal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)7 Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
El Yes C No ETC-.
3 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?
liPif ❑No ❑Yes I
Taring district Key number/Legal description Record number(contract) Page number(contract)
1 11-V - -poi -cot- gac-pall
I)We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature Ppfrant .�j� Address of applicant (number and street,city,state,and ZIP code) •
/ Signatu o a moraed/e /Ken tire Add of authorized represeniii555ti555e (number and street,city,state,and ZIP code)