Disabilty_Goldman Jr a APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
,, DEDUCTION FROM ASSESSED VALUATION
-
i,� t State Fonn 43710(R12/10-16) `;y� t {Tj ,(� `/'�I
S., ' Prescribed by the DepaNnent of Local Government Finance j13" I ` `''" (CV I 1
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 mail with the County Auditor of the county where the property is located.
Ring Dates: 1) Real Property.Form must be completed and signed by December 31 end 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.N.•..- •fapplicant(• a : contract uyer) V
now L JUrinot J o T
applicantv -
Is appnt the • -__;;Ea equifa owner? If No,what is er exact share to with someone other than spouse,
to with
Ap ❑NoIf name on record is differentpluanL indicate below:
JUN 12 2019
Name of contract sager
GIBSONNT AUDITOR
Address of contract seller(number and sheet,city,state,and ZIP code) I property in question:
Real Property 0 AnnuallyAssessed
Mobie Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and a to ngage in any substantial gainful activity
ao
as efined in IC 6-1.1-12-11(d)?
❑Yes Yes ❑No
Ls the property used and occupied pdmanly for hsidence? Does the applicants taxable gross income for the mg calendar year
exceed 517,000?
Yes ❑No es ❑No
Taxing district Key number/Legal description Record number(cot
Q Page number(contract)
,Z;$ - 11 -1-Z-Zo4-600 -02,8
UWe 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�14y)t 4.01 E Cribreesfi��1 ? -h -3n-kW -° .
Signature of orized represen dress of authorized representative (number and street,Aryl state,and LP code)