Disabilty_Wright APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
ea,, DEDUCTION FROM ASSESSED VALUATION ����
State Form 43710(R12/10-16) 91Sn
S ,.1. Prrscrrbed by the Department of Loral Goverment Finance 1 .
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
Ma 1 ar the individual wishes to obtain the deduction.
See reverse sides r additional instrudfon d qualifications.
N ap icant(owner or contractbt) [� (1 1(vd,+\J^ �t •
j—�J� �( C
•
own If No,what is - exact share of interest? V If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No FILED
If name on record is different than that of applicant,indicate below:
Name of contract secret AUG ` ��q]f 0 9 2019
Address of contract seller(number and street,city,state,and ZIP code) �(-- �} I property in question:
GIBSOJJN COUNTY AUDITOP RealProperry ❑ AMualyAsses
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? . Is applicant disabled and a to e age in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)? Ary
ElYes o ❑No
Is the property used and occupied primarily for h idence? Does the applicant's taxable gross income for the g calendar year
exceed S17,000?
tplYes ❑No Ita4 El No
Taxing district �/ Key number/Legal description Record number(co/tractt Page number(contract)
\ o�. all- 118-13- (bt-000 .01Li - 25
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
• re of pfcant Address of applicant (number and street,city,state,and ZIP code
•
ignatur of representative`. .� Address of authorized representative (number and street,city state,and ZIP code)