Disabilty_Dishon APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
. Qm.' DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. TF
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Frog Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by thgfpI1pi. g J�5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly.�D g the12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
atifi ;t
Namhe of applicant ow/r�ier or contract eulyer)ry/ �1 �,("�/ GIBBON COUNTY AUDITOR
/lJ4/L K"_ d �Q� Jf` nA oi-
ls 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 whom
XYes ❑No
If name on record is different than that of applicant,indicate below
Name of contract seller /
nal
Address of contract seller(number and street,rity,state,and ZIP code) Is the property in question:
0 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 \14Yes ❑No
Is the property used and ocapi manly for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
(Yes ❑No El Yes %No
Taring district /" Key number/Legal description Record number(contract) P ge number(contract)
700 t--- ((-i7-O/-3COal. )'701-0a,,
Me certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of appi' nt ( \ (' l Address of applicant (number and street,city statel.and ZIP code)
\pp C��-� *� • )p ?b J Y (n! h �11ortA(AG(f 0V\1&Wensv7113 7, (17465
Signature of authorized representative \4ddress of authorized representative (number and street,city,stale,and ZIP code)