Disabilty_Weigle "z.k" APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
ii :.' DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
S I Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS: FILE ,Tofiled
To beinnperson 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(Milne tde twelve F12)months before
March 31 of each year the individual wishes to obtain the deduction. CL 1�, LL a L U l D
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer) .l)/-
(,Z I 1, : - GIBSONNJ$C�OUI TY AUDITOR
Is applicant the sole legal or equitable owner? If No, , t is his/her exact share of interest? - If awned with someone other than spouse,
indicate with whom:
ale( ❑No
If name on record is differentindicate
than that of applicant below:
Is party in question:
Real Prope y ❑ AnnuallyAssessed
Mobie 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 ❑Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable grass income for the preceding calendar year
exceed S17,000?
❑Yes ❑No ❑Yes o
Taxing district Key number/Legal description Record number(contract) Page number(contract)
a( - Id -01 - spa - ooa. 3')i-tag
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)
x (141/ 4/6 Ct/ ,,o� (931 S k0 Pfr, n 117670
Signature of authorized representative Address of authorized representative (number and street,dry,state,and ZIP code)