Disabilty_Graves "• APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
\� ` ' State Form 43710(R9/9-08)
s
Rae f Prescribed by the Department of Local Government Finance 11111
0lformation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). =M='
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the property is located. J U N 26 2017
Filing Dates: 1) Real Property:During the year for which the deduction is sought.
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. �/(�l
Name of applicant(owner or contract buyer) GIBSON COUNTY AUDITOR
MCIAla E
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:
"eS ❑No
If name on record is different than that of applicant,indicate below:
---- "--._`
Name o contract Belle —;p-."`✓ .
Address ofEdsr(n
(nPr.er and streef,_city state,.and ZIP-code) -— Is the property in question: 0
^-- El Real Property ❑ Annually Assessed y\
��� Mobile Home(IC 6-1.1-7)
Is applicant blind as defined-in I-C 12�-2-21(1)? Is applicant disabled and unable to engage in any substanti gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes 0 No Yes 0 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?
❑Yes ❑No ❑Yes No
.axing district Key number/Legal description Record number Page number
C9(0 ''' I a ..t t‘ii '.. ICO 000` gOg°°' 02 ,
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20 .
Signature of applicant ii Address of applicant (number and street,city,state,and ZIP ode)
alure of horized representative Address of authorized representative (number and street,city,state,and ZIP code)