Disabilty_Stamper ,cs!z APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
%`-'=% DEDUCTION FROM ASSESSED VALUATION
5 �L State Form 43710(R13/1-20) ^���
"\,a1e�'' Prescribed by the Department of Local Government Finance C%
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: •To be filed in person or by mail with the County Auditor of the county where the property is located. •
Filing Date: Form must be completed and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
(Lk nn1 e_ A 3I fn per (JeD) ,/
whom:
Yes ill 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 pro 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 es ❑ 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 le No
Taxing district Key number/Legal description Record numbericontract) Page number(contract)
govidcyz, - 4-20-`O,r-'cj�—CD/. p 2?CD/
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)
xvd,, # 7i35�' Soo ,..5/ J4a'Z &J) 2W974L9
Signatu al -uthoriz�• :presentative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day,year)
Unn, 4 Spr 8I2-3vL71-917145
Name of contract seller F IL 1-4,D
Taxing district NOV 2020
6,0,-,, 5
Key number/legal description4.4.ciati_ci...
GIBSON COUNTY AUDIITOR
240 •2,0 O 5- Li 0 0 e)t)I.
,D7- eD /Signature of County _Auditor Date signed(month,day,year)