Disabilty_Allerellie _APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
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. State Form 43710(R12/10-16)
iv.
S Prescribed by the Departmentof LocalGovernmentFinance 1
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 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 G Du1�d
nyl1 J,t` � �►1\V Pr k`eve 1 k
Is applicantother
the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone than spouse,
indicate with whore
2\p ❑No
If name on record is different than plkant,indicate below. l LE
x1,1
r
Name of contract seller 1
er MAY
/� 4 2019
Address of contract seller(number and street,city,state,and ZIP code)
J/Lp� Is�1t roperry in question:
GIBSONNN77CltOUNTG �ProY ❑ �Ma
AUDITOR J�\n�j 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 e age in any substantial gainful activity
as defined m IC 6-1.1-12-11(d)?
❑Yes ❑No th4s ❑No
occupiedIs the property used and primarily for his/her residence? Does the applicant's taxable gross income for r rig calendar r
exceed$17,000?
kes ❑No ❑Yes No
Taxing district Key number I Legal description Record number(contract) P g number(contract)
t1)\n wl 1130 b 4-14-�03-o 03 log-o\Q
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
er: t Address of applicant (number and street,city,iQte,and ciV
• nta t
Address of authorized representative (number and street,city,state,and ZIP code)