Disabilty_Kidd APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
\ ;= DEDUCTION FROM ASSESSED VALUATION
Y"' '` State Form 43710(R12/10-16)
5 - 1 Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. y ark
INSTRUCTIONS: FILE
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 following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real PrrWly:Purir OIjf twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name ofa t(owner or contract buyer) !!��
�U t< 11 II GIBSON COUNTY AUDITOR
Is applicant the legal or equitable owner? If No,what(, is his/her exact share of interest? - If owned with someone other than spouse,
indicate with wheat
Lutes ❑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 in question:
Real Properly ❑ Annually As
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined hi IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12d1(d)?
❑Yes ❑No 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? /
❑Yes ❑No ❑Yes O
Taxing district Key number/Legal description Record number(contract) Page number(contract)
C -1,-Di-IDa- Dai. TVIDat'
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)
7uthar�d CE1 q AJ K� P- -,JL26xb
Sig re representative Address of authorized representative (number and street,city,state,and ZIP code)