Disabilty_Hosmer (2) esrk APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a` t ?
.i -L;,. DEDUCTION FROM ASSESSED VALUATION i 1(`1
��
State Form 43710(R12/10-16) I ii-cuJ°
',;:-esPrescribed by the Department of Local Government Finance lI V V1
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 p arked by • •wing Janua
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed ea Prop :a 4 the elve(1 months before
March 31 of each year the individual wishes to obtain the deduction. �
See reverse side for additional instructions and qualifications.
1
N e o ppliq (owner or contract buyer)
5 -60.. cif\CA . -
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? wned with someone other than spouse,
icate with whorrr
No FIlLED
If name on record is different thaAYtes
applicant,indicate below:
Name of contract seller O C T 1:5 2019
Address of contract seller(number and street city,state,and ZIP code) G I B S O N CO A" Ul'�''m uest"ion:
►1 "eAati'ropevrg ❑ AnnuallyAssessed
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-i2-11{d)?
❑Yes o ❑Yes o
Is the property used and occupied primarily for h /her r idence? Does the applicant's taxable gross income for the preceding calendar ear
exceed$17,000?
XYes 0 No ❑Yes No
Taxing district Key number I Legal description Record number(contract) anumber(contract)
( — \C -31 -30 1 -°00 3sL .-off
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)
) 9w.k..4.0t -tAtzmex, 30Li 3 11,i, J I\� -J n - LITO9
Signature of authorized representative Address of authorized representative (number and street,city,Mate,and ZIP code)
1
I
i
2300 N GREEN RIVER RD
EVANSVILLE IN 47715
,
t
Other Help For Seniors
Call the Eldercare Locator service of the U.S.Administration on Aging at 1-800-677-1116
or visit www.eldercare.acl.gov to learn about a wide variety of services that may be
helpful to you.
1
L
R
BNC#: 18B1775D.94793
Over ►