Disabilty_Dunning (2) F., APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a'`�';}Y DEDUCTION FROM ASSESSED VALUATION
Sri, ^-L: State Form 43710(R12/10-16) lso.r) f i k9
."-, j Prescribed by the Department of Laced Government Finance Jt'^"— 1 I WSr 2` 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.
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 side for additional instructions and qualifications.
Name cant(owner or con
pr . I (Nnn i
Ls appfice t the sole legal or equitable owner? If N ,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom¢
Yes ❑No LED
If name on record is different than f applicant,indicate below: AUG�J
Name of contract sefier HUG 8 2019 '
.
Address of contract seller(number and street,city,state,and ZIP code) GIBSON 1a
uIT '
•Real Rowdy a AnnualyAssessed
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 defined in IC 6-1.1-12-11(d)?
❑Yes ❑No Yes ❑No
Is the property used and occupied primarily for histher residence? �Does the applicant's taxable gross income for the ace mg calendar year
exceed 517,000?
•
XS ❑No /.NYes ❑No
Taxing district Key number/Legal description Record number(chntra t) Page number(contract)
av 1z=c.)-tioo -coo . 5-16-09-:
WVe certify under penalty of perjury that the above and foregoing information is true and correct.
of applicant Address of applicant (number and street,city,state,and ZIP code)
.�, 6. g Li N � id al
r ^— ,` - -uc
Ae.Sgnature o authonzed representative ress of authorized representative (number and street,city,state,and ZIP code)