Disabilty_Curtsinger .
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a- <r1;1 DEDUCTION FROM ASSESSED VALUATION ��1
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6. :�"- 4 " State Form 43710(R12/10-16)
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, / Prescribed by the Department of Loral Government Finance IJJ
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the properly 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 Properly:During the twelve(12)months before
March 31 of each year the indMdual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
N of appftcant owrxr orconbad buyer)
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Is ap t the sole legal or equitable owner? If No,what i her exact share of interest? If owned with someone other than spouse,
indicate.,who=
plYes ❑No iCIJ_ 11 ., . tn 171L/AC�AI�
If name on record is different than t applicant,indicate below?ILE 1'DI ,
Name of contract seam JAt N 152019t�'
Address of contract seder(number and street,dty,state,and ZIP code) 1 1L., Is in question:
GIBSON COUNTY AUDITOR eel Property ❑ 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
A
as efned in IC 6-1.1-12-11(d)?❑Yes 9(J Yes ❑No
Is the property used and ompied primarily for hxtence? Does the applicant's taxable gross income for the r irg calendar year
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exceed a17.000? ���///❑No CYes ❑No
Taxing district Key number/Legal description Record number( �) Page number(contact)
? `fin . lib —12—Ag-tot-oo1 .680 - o2S .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
re o ap Address of applicant (number and street,city.state,and ZIP code)
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Sig re`a re five Address of authorized representative (number and street city,state,and LP code)