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Disabilty_Cousert APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
- '- State Form 43710(R12/10-16) •
C��'I Prescribed by the Department of tool Government Finance
Fil
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: 11fL'
To be filed in person or by mail 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 fol(gll inaiii9gp141
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:D I ( )months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. /)r
Name of applicant(owner or contract buyer) GIBSON COUNTY AUTOR
j)laaa n COU5OAf-
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If arced with someone other than spouse,
indicate with whorrc
Ad'Yes ❑No
If name on record is different than that of applicant,indicate belay.
Name of contract seller
Address of contract seller(number and steel,city,state,end ZIP code) Iss the p rty in question:
0 Real Property ❑ Annually Assessed
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 engage in any substantial gainful activity
as efined in IC 6-1.1-12-11(d)?
❑Yes No ❑Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed S17,000?
❑Yes ❑No Yes ❑No
Tatting 'stria _1�,,,, Key number/Legal description Record number( ct) Page number(contract)
bolo r t 4 Lt • ao- 5- C 'toact•./W�- 26"Ho, 00283_ap
liWe 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)
I� i Q nn 5l33 LI- )(24,�9C!) 9 70'9
Signature of authorized representative Address of authorized representative (numbd argstneet,city,state,and ZIP code)