Disabilty_Jefferies APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16) FILED
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: JUL 3 0 2018
To be filed in person or by mail with the County Auditor of the county where the property is located. '
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the folio Ir Janu. 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:Duri • , r, -uff hi• • the before
March 31 of each year the individual wishes to obtain the deduction. G I BSO N COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contact buyer)
P 0. a Qnn
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? • If owned with someone other than spouse,
� � indicate with wt
L�IYes ❑No
If name on record is different than that of applicant,indicate below:
Name of contract sager
•
Address of contract seller(number and street,city,state,and ZIP code) is the pre in question:
eal Property ❑ AnnualyASSessed
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 LIF1Vo - ❑Yes ❑No
Is the property used and occupied primarily for his/her residence?' Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
L.Y'Yes • ❑No ❑Yes Et
Taxing district
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Ad of applicant (number and street,city,state,and ZIP code)
•
Si hire of authorized representative terve (number and street city,state,and ZIP code)