Disabilty_Shawgo (2) n APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
S State Form 43710(R12/10-16)
Gibson
Prescribed by the Department of Local Government Finance
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 Propert gettwe 1.1 'ths before
March 31 of each year the individual wishes to obtain the deduction. ggif
See reverse side for additional instructions and qualifications. 4' (
Name of applicant(owner or contract buyer)
Dale A Shawgo JUL 2 9 2019
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with sorp§ ne other an
indicate with wf
IA Yes VNo GIBSON COUNTY AUDITOR
If name on record is different than that of appl' to below:
Name of contact seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
ii 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 actN ity
as defined in IC 6-1.1-12-11(d)?
❑Yes O No O Yes ❑No
Is the property used and occupied primardy for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
❑� Yes ❑No ❑Yes ❑No
Taking district Key number/Legal description Record number(contract) Page number(contract)
Ft. Branch 26-19-18-303-000.319-026
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature f applicant
Address of applicant (number and sheet,city,state,and ZIP code)
C 114TO 205 S Willard Ave, Ft. Branch, IN 47648
Signature of authorized representable Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Name of applicant Date fled(month,day,year)
Dale S hawgo
Name of contract seller
Taxing district
Ft. Branch
Key number I legal description
26-19-18-303-000.319-026
Signature of County Auditor Date signed(month,day,year)