Disabilty_Shafer APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
- ;r. DEDUCTION FROM ASSESSED VALUATION
State Form (R12 t 10-16) '
Prestnbed byy the the Deparbnad of Local Government FinanceInformation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. FT_
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INSTRUCTIONS: '
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Ong Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the faltering Barr oma
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:DunW a fweVIW 12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer) GIBBON COUNTY AUDITOR
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Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? . If owned with someone other than sparse,
indicate with whom
RYes ❑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:
❑ RealPtu.aty ❑ AnnuallyAssessed
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 YCNo ❑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 S17.000?
Q'Yes ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
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I/We 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)
<rn?tiphL3Ns'RsSignature of au0mrzed representa Address of authorized representative (number and street,city,state,and ZIP code) tjr1 tsU
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