Disabilty_Dunn (2) f�.
sr. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
sili' `a DEDUCTION FROM ASSESSED VALUATION
a State Form 43710(R13/1-20) Gibson 028 2020
1B%' 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
' .
Name of applicant(owner or contract buyer)
Beraglia, James P yan M Dun
Is applicant the sole legal or eq If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
IYes ❑ No
If name on record is different than that of applicant,indicate below: I
F
LED
Name of contract seller
NOV 12 2020
Address of contract seller(number and street,city,state,and ZIP code) . egproperty in question:
GIBBON COUNTY l I IeaLProperty ❑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 l] 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?
0Yes ❑ No ❑ Yes 0I No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
028 26-12-07-101-000.486-028
.l' I certify under pen of perjury that the above and foregoing information is true and correct.
,Si re of applicant),,,, Address of applicant (number and street,city,state,and ZIP code)
•
406 W Spruce ST, P'ton, IN 47670
Signature aut rized representative Address of authorized representative (number and street,city,state,and ZIP code)
ii
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