Disabilty_Barnett ', APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY I TOWNSHIP it YEAR
ate.
;A - g DEDUCTION FROM ASSESSED VALUATION
T'-1"''!" State Form 43710(R12/10-16)
S > Prescribed by the Department of Local Government Finance ar1r.
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-359. F r M Nom/ p
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county wham the property is located.
Filing Dates: 1) Real Property Form must be completed and signed by December 31 and filed or postmarked by the fdIo i�p{� u�3'5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:Durin9Yii' hub(aQ1181onths before
March 31 of each year the individual wishes to obtain the deduction. l�
See reverse side for additional instructions and qualifications. - J 1r
Name of applicant(owner or contract buyer
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n (� GIBSON COUNTY AUDITOR
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Is applicant the sole legal or egpf4ble owner? No,what isrdsffer exact share of interest? If owned with someone other than spouse,
Uindite with whom
❑Yes ❑No
If name on record is different than that of applicant indicate below:
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is the property in question:
.Y Real Property ❑ Annually Assessed
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 ❑No pYes ❑No
Is the property used and occupied pdmanly for histher residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
2 l< -a0-i/ - ZO / OOOg3t, 003
IA 'e certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code) �� .(�
• `I ICJ 17 I •Jl - /N AIL ! 7606re
,Signature of ar . .•represe•tative Address of authorized representative (number and sheet,oily,state,and ZIP code)
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