Disabilty_Dearing an• APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Fonn 43710(R12/10-16)
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Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. -File Ma -
INSTRUC7IONS: DEC 1 8 Z018
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 Property:Dudii e' months before
March 31 of each year the individual wishes to obtain the deduction. GIBBON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
• E -De C3 r\
Is applicant the sole legal or 46,ovmeR If No,what is his/her exact share of t? If anted with someone other than spouse,
indicate with wham
Id Yes ■No
If name on record is different than that of applicant indicate belay.
Name of contract sera
Address of contract seller(number end street,city,state,and ZIP code) Is the m quesfion:
eat Property ❑ Annually Assessed
Mobie Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)7 Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes EPIC 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?
DAC ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
alp a3-�v - aoo -- coo _ 722- oo9
UWe 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)
•
Signature of aulhoibfrad representative Address of authorized representative (number and sheer,city,state,and ZIP code)