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3 � °' : APPLICATION FOR BLIND OR DISABLED-PERSON'S COUNTY TOWNSHIP YEAR
I .,:DEDUCTION FROM ASSESSED VALUATION
Z Stem Form 43710(R12r 13.1e) 1I/�A/. 'n�/7
Preached by the Department or Loci/Government Finance �7,/)s C1'1 vun44 t G'v l9
i
Information contained In this doaimerd is CONFIDENTIAL pursuant to IC 6-1.1-35-9. Ftle Mark
INSTRUCTIONS:
lb be Med In person or by ma3 veil the CountyAudifor of the county where the poperty Is located.
FTaw Dater 1) Real Property Form must be completed and signed by December 31 and Ned 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 bidMdual wishes to obtain the deduction.
See reverse side for additional Instructions and qualifications
, Name of extant(owner or mibat buyer)
NIthat t,arilJay
b appa®nt Pe sole legal or egdtade owneR 1f No•what Is NSRxer exact sham of interest? t owned with someone otter ban spouse.
Indicate with wham
•
Yes ❑No
a name on romdle diferenl than Cof applkam,Indicate below.
Name of rated shear
Address of mina sear(number and shear,din.state end ZIP code) property nques9orc
• p r Real Property ❑ Amua11yAssessad
WAG Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12.7-2-21(1)7 Is appiloonl
d disabled and unable to engage n any subctandsl gainful eaddly
Man
ed nced n IC 6-1.1-12-11(d)? \�
Dyes 0 No the pramdgg ❑No
Is the property used and occupied primly for Meter residence? Does theapprcenCe taxable gross income for
ppp��� abrWx year
exceed f170007
Yes ❑No Dyes ONo
Taxing //////����`` Key number I Legal des cipam Record number(contract) Page number(contract)
n �1, O h45O 2‘)-2)-12 3 )6 -ooz- /— aa9
IWe certify under penalty of perjury that the above and foregoing Information Is true and correct -
Hx
1natire of applicantof appimrd(number and sheet,dry.stale.and ZIP code)
72 P u z, Tg/t7S41 5 150 tJ laubt„,frriz-A, 976,3 7
Signature of authorized rapresenaWe / Address of authorized repreaenlaWe (number and sires(city,stab,end ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Name deppswxt Date
L D
Name ofcot art seas
AUG 07 2019
Tway • .
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I tJt 11SW �1101& 1.I��
l Key number. lapet aaWlpdm GIBSON COUNTY AUDITOR
4 22-1. -3c-D42 , D61 — Da 1/-
2. Signature ci County Auditor Dab signed(monam,day.lead
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