Disabilty_Hipp •
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
6- DEDUCTION FROM ASSESSED VALUATION � —State Form 43710 epart ent )
o ^ 1 \ I .~ Slate lied by the Department of local Government Finance y ' 1 `cs_J4• CJ��
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 Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse si�adddt6onal instructions and qualifications.
N t(owneroroon buyer)
iv.)
1T Ift4�J •
app6ce a sole I • le owner? Y(1`0,.nat is/er' share of interest? - If owned with someone other than spouse,
`� V I indicate with wloru:
❑js CI No F' �I13
If name on record is different than th of ploant,I Noa[e belovr.
Name of contract seller ,M/�tAY 1 5 2019 ,
Address of contract seller(number and street,city,state,and ZIP code) )a I property in queston:
GIBBON COUNTY AUDITOR0. eaIProperly ❑ NlnttalyAssessed
-r
Mobile Home QC 6-1,1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Isa defined
applicant IC unable7 to engage in any substantial gainful activity
(d)?
❑Yes t[ e �° es ❑No
Is the property used and occupied primarily for h r erica? Does the applicant's taxable gross income for the calendar year
exceed S17,000?
Ces ❑No ❑Yes o
Taxing çç
Y \ Key number1 Legal description Record number(contract) age mbar(conract)
4^ P8 -3 to -Lk()3-o op . g°t8-o09
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\/y/�J/) r gam. 1\0 s \l onno, - Lin / -3 n t, 39
Sign re oriz d re nti r Address of authorized representative (number and street,city,state,and ZIP code)