Disabilty_McCoy 4.0.-4ea, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
_ DEDUCTION FROM ASSESSED VALUATION
5K.., Lt I' State Form 43710(R13/1-20)
Gibson 027 2020
ri-4' Prescribed by the Department of Local Government Finance
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
Name of applicant(owner or contract buyer)
Herbert McCoy
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:
WI Yes ❑ No
If name on record is different than that of applicant,indicate below: 1
Name of contract seller N O V 1 0 2020
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Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
GIBBON COUNTY AUDITOR iZI Real Property 0 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 i1 No ®Yes ❑ 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?
IZ Yes ❑ No ❑Yes VI No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
027 26-11-16-200-004.144-027
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applica Address of applicant (number and street,city,state,and ZIP code)
� -773 S 350 W, P'ton, IN 47670
Sim g ature 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 applicant Date filed(month,day,year)
Herbert McCoy
Name of contract seller
Taxing district
027
Key number/legal description
26-11-16-200-004.144-027
Signature of County Auditor 1 Date signed(month,day,year)
In A :tif\ 11/10/2020