Disabilty_Minnis (3) •
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
---kt24i DEDUCTION FROM ASSESSED VALUATION
State Form 43710(e12 t10.16)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. • it rk
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the properly is located. ��tr�� 'i
Filing Dates: 1) Real Properly postmarked Form must be completed and signed by December 31 and filed or posarked by the followingocui ary 5! 2018
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Nameofapplicant(owner or contact buyer) GIBSON LOU I Y AUDITOR
e- C er • PIN1rlCltS
Is applicant the sole legal Kai-. itable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
lldYS No
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and sheet,city,state,and ZIP code) Is�ttheproperty in question:
Ild"RealProperty ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is app icant disabled and unable to engage in any substantial gainful activity
�/
as defined in IC 6-1.1-12-11(d)? /
Yes- L7No Ctl-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 517.000?
LN Les ❑No ❑Yes I,J-N1.
Taxing district Key number t Legal description Record number(contract) Page number(contact)
I)We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant n�1 Address of applicant (number and street,city,state,and ZIP code)
•
gCco6- r-CI le Pt
Signature of uthorized representative Address of authorized representative (number and street,city slate,and ZIP code)
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