Disabilty_Deibler tin APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
lt DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
• Prescribed by the Department of Local Government Finance Gibson 2019
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-I.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 of applicant(owner or contract buyer)
James M. Deibler
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse.
indicate with whom:
❑O Yes ❑No
It name on record is deferent than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ 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 defined in IC 6-1.1-12-11(d)?
❑Yes O No O 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$17,000?
1D Yes ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
Johnson Twnship 26-23-02-300-001 .870-024
INVe 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)
10848 S 350 E, Haubstadt, IN
Signature of authorized representative 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
James �M. Deibler
Name of contract seller
AUG 222019
Taxing district
Johnson Twnship
Key number/legal description GIBBON COUNTY AUDITOR
26-23-02-300-001 .870-024
Signature of County Auditor Date signed(month,day,year)
, , c_4_ 1 08/22/19