Disabilty_Turpin APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
°(; -k DEDUCTION FROM ASSESSED VALUATION
- '= State Form 43710(R12/10-16) ye%' ILED
1a
�eie Prescribed by the Department of Local Government Finance
information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS: NOV 0 1 2019
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:Fonn must be completed and signed by December 31 and filed or postmarked by the following Jan
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property: rin (12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. .
GIBBON COUNTY AUDITOR
Name of ap 'cant(owner or contract buyer) (At)
aiktil I
Is applicant the sole legal or equitable owner? If o,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑NO
If name on record is different than>dY,eS
at of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) I the perty in question:
Real Property ❑ AnnuallyAssessed
Mobile Home(IC fr1.1 7)
Is applicant blind as defined in IC 12-7- -21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
e ❑No ❑Yes ❑No
Is the property used and occupied rimarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes ❑No
Taxing di trio Key number/Legal description Record number(contract) Page number(contract)
Otidlei/v-it
74'Ai 5cm 632— 60-9. F/5'. e)/9
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
S• natur/ fI/applicant Address of applicant (number and street,city,state,and ZIP code)
dF.7„,..--"1.44). ----
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of- plicant Date filed(month,day,year)
aiyut 4 FILED
Name of contract seller
NOV 01 2019
Taxing district
64/044/V2.
GIBBON COUNTY AU TO
Key number/legal de cription R
210-0 z. ,6'9 . n3zzoo. z/5 - 0/9
Signature of County Auditor Date signed(month,day,year).