Disabilty_Blackard z.
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
N DEDUCTION FROM ASSESSED VALUATION
''.:.ck;m rn Presbed by the Deparhnrari of Local Government Finance V 019
I�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 marl with the CountyAuditor 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: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 of applicant(owner orconbact buyer)
A 11e A 2 lAp,dvccw
Is applicant the sole legal or equitable owner? If No,what is hismer exact share of interest? If owned with someone other than spouse,
indicate with wtonx
No
If name on record is different than is t applicant uMicate below: FILE I,)
•
Name of contract seller MAY 8 2013
Address of contract seller(number and street,city,state,and ZIP code) N'r� I e property in question:
GIBBON COUNTY AUDITOR Real Rupeity D AnnuatiyAssessed
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 ngage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)? &es
Yes ❑No ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the Bg calendar year
exceed$17,000?
)(S ❑No Yes ❑No
Taxing district O Key number/Legal description Record number(co ct) Page number(contract)
Cji , c� 11 c4rVM—II —300 -000.a63 -oay—
�r
IIWe 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 a a s 2044CA et-- G3tkS s Leko o -y()
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)