Disabilty_Young APPLICATION FOR BLIND OR DISABLED PERSON'S
,t COUNTY TOWNSHIP YEAR
� ; DEDUCTION FROM ASSESSED VALUATION
it:4\C -,' States Form
ed 43710 the (ep 6) ��~ I l l tr ZoI tit
S I Prescribed by the Department of Local Government France rL �1I
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS:
To be Ned in person or by mail with the County Auditor of the county where the property is located.
filling 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 ' '. nal instructions and qualifications.
N f applicant(owner or tract
interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
If name on record is different than that of applicant,in E ) )
Name of contract serer SEP 3 2°19
Address of contract seller(number and sheet,city,state,end ZJP d " µ{ •
Is the perty in question:
GIBBON COUNTY AUDITOR Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applcant band as defined in IC 12-7-2-21(1)? Is applcant disabled and u e to engage in any substantial gainful activity
sz as defined in IC 6-1.1-12-11(d)?❑Yes k es ❑No
Is the property used and occupied primarily forxlence? Does the applicant's taxable gross inane for pr g calendar year
exceed$17,000?
Yes ❑Noes ❑No
Taxing district Key number/Legal descdption Record number(contract Page number(contract)
26— Iq-1 t -204 -oo k .341 -026 .
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
• Lure of applicant Address of applicant (number and street,dry:state,and ZIP code)
f' f/& wit /�� • 42 g �qo S Pf 1Evar3,1 �(1 - 119-dk'Y
S nature of authorized represen e / Address of authorized representative (number and street,city,state,and ZIP code)
The following chart shows your benefit amount( s) before any
deductions or rounding. The amount you actually receive may differ
from your full benefit amount . When we figure how much to pay you,
we must deduct certain amounts , such as Medicare premiums and
worker ' s compensation offset . We must also round down to the nearest
dollar .
Beginning Benefit Reason
ENCLOSURES :
PUB. NO. 05-10153 PUB. NO. 05-10058
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