Disabilty_Conklin 7; .—•
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
4 ;,. DEDUCTION FROM ASSESSED VALUATION• ' State Form 43710(R12/10-16)
S '•-- Presaibed by the Department of Local Government Finance ki �n�`nnv"'l
in
•
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 Properly.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:During the 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 applicant(owner or contract
a I
JA
N ap �atthasakbeg�'�ui de owner? If ,what is his/her ct yMil 'of t 6r(^�i I If corned with someone other than spouse,
indicate with wtrrnr
*.s 0 No
If name on record is different thanpplicant,Indicate below: IL
F
Name of contract seller MAY 6 2019
Address of contract seller(number and street,city,state,and ZIP code) _.,m.�,; property in question:
' . J6f1fi¢erty ❑ Annually Assessed
GIBBON COUNT 1° MobfleHome(IC6-1.1-7)
Is applicant blind as defined in IC 12-7.2-21(1)? Is apy�nt disabled and anode to-ngage in any substantial gainful activity
as ed fined in IC 6-1.1-12-11(d)?
ID Yes ❑No C es ❑
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the yt ng calend ar
exceed$17,000? —/
es ❑No ❑Yes o
Taxing district Key number I Legal description Record number(contract) Pa a umber(contract)
r 1 loAtit\ - x-\T-U -tot--00\ .12-6 - oZ6 _ .
I)We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature o ppGant j(linsign
Address of applicant (number and t,city,state, ZIP code)
Ak
-.3o2 Venn kIlt1 ittrand, r 1 .
lure of authorized representative Address of authorized representative um and street,city,state,anA ZIP code)