Disabilty_Humphrey q7 APPLICATION FOR BLIND OR DISABLED PERSON'S
! ' g DEDUCTION FROM ASSESSED VALUATION COUNTY TOWNSHIP YEAR
"= State Form 43710(R12/10-16) 1
e ,,,, e' Prescribed by the Department of Local Government Finance VI
Coil . e2-02- .
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. J
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 ofap licant(ownerorcontractbuyer)
J ccyui i cd,r1 -Nuyil
Is applicant the sole legal or equitable owner? If No, at his/her exact share of interest? If owned
with someone other than spouse,
indicate with whom:
Yes ❑No
If name on record is different tha at f applicant,indicate below:
Name of contract seller J U L 3 I. 2020
•
Address of contract seller(number and street city,state,and ZIP code)
GIBSON COUNTY AUDITOR I property in question: -
Real Property ❑ 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 6-1.1-12-11(d)? '
❑Yes k\lo ❑NoIs the property used and occupied primarily for hiesidence? Does the applicant's taxable gross income for the es receding calendar year
exceed$17,000? ,
Yes ❑
Signature of applicant)(
Address of applicant (number and street,city,state,and ZIP code)
9A,, tiv44er_ 2623 S r. E
, CO3LOotil A cf,A -3Y\ -\-9-64-0
Signs re of authorized representative Address of authorized representative (number and street,city,state,and ZIP code) ,
269-0271 (TTY 1-866-501-2101).
If You Have Questions
We invite you to visit our web site at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you may ,
call us toll-free at 1-800-772-1213, or call your local office at 877-800-7585. We can ,
answer most questions over the phone. If you are deaf or hard of hearing, you may
https://secure.ssa.gov/mySSA/startrp 7/30/20, 6:10 PM
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