Disabilty_Schmitt t",4 APPLICATION FOR BLIND OR DISABLED PERSON'S couNTY TOWNSHIP • YEAR `— . ��;: DEDUCTION FROM ASSESSED VALUATION a := State Form 43710(R12/10-16) O y „.,,. ✓' Prescribed by the Department of Local Government Finance Gibson 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 of applicant(owner or contract buyer) Dawn A. Schmitt 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: ❑■ Yes ❑No If name on record is different 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 ❑■ No ❑■ Yes El No Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year exceed$17,000? ❑■ Yes ❑No ❑Yes ❑No Taxing district Key number/Legal description Record number(contract) Page number(contract) Owensville 26-17-01-404-000.606-022 I/We 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) 06,-17\ CA. J4:41A-- 503 N. Third St., Owensville, 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 filed(month,day,year) Dawn A. Schmitt Name of contract seller FILED Taxing district O C I 2 2019 Owensville Key number!legal description 26-17-01 -404-000.606-022 GIBSON COUNTY AUDITOR Signature of County Auditor Date signed(month,day,year) kRL-1 )\ -- cLLL-k- J 10/02/19