HomeMy WebLinkAboutDisabilty_Riley ;ti'• APPLICATION FOR BLIND OR DISABLED PERSt :S COUNTY TOWNSHIP YEAR
e DEDUCTION FROM ASSESSED VALUATION 4.---;
S� •!,...- '` State Form 43710(R12/10-16) iri) %., r
S .«! Prescribed by the Department of Local Government Finance ppg 4p$
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. He 'ark
INSTRUCTIONS: JUL 0 9 2018
To be Wed in person or by mail with the County Auditor of the county where the property is located.
Fang Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked b the following J null .
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Proppr�t• elve(12)months before
March 31 of each year the individual wishes to obtain the deduction. GIBSON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
N1Wa- ck- 3enrvol LI
Is applicant the sole legal or equitable owner? If No,what is his/her exa sf of interest? If owned with someone other than spouse,
indicate with whom:
0 N
If name on record is different than that of appfirani,indicate below:
Name of contract seller
Address of contract seller(number and sheet,city,state,and code)
Is he in question:
639 L ev t^�I 1� / Real Property ❑
Annually Assessed Mobile Home(IC 61.1-7)
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 No es ❑No
Is the property used and occupied pdmanly for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000? _ /
es 0 N ID Yes O
Taxing district Key number/Legal description Record number(contract) ge number(contract)
Q - (&6 —OA -2s= LAO 0 - 0 0 63y-0 2.0 .
I)We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of
/J ,-v Address of applicant (number and street,city,state,and ZIP code)
X 'tad �C X (P3Q 4. a-P� a- �- Pc k.c. , I N Li-N4(04.4
Sigma] authorized representativ Address of authorized representative (number and street,city,state,and ZIP code)