HomeMy WebLinkAboutDisabilty_Davis (5) .M ^•N APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
4I DEDUCTION FROM ASSESSED VALUATION
100 ' State Form 43710(R13/1-20) /{)2 ���
,elm a Prescribed by the Department of Local Government Finance • ,�\)') v .
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 file..ar ostmarked 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 buy
•
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:
Yes ❑ No •
If name on record is differerit than et o applicant,indicate below: ¢'-9
F IL
1-:
a..
Name of contract seller
NOV 2 0 2020
Address of contract seller(number and street,city,state,and ZIP code) /�, Is roperty in question:
�J/�/W�c Real Property ❑ Annually Assessed
GIBSON C NTY AUDITOR Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unab to engage in any substantial gainful activit
as defined in IC 6-1.1-12-11(d)? ,/
❑ Y No Yes i No
/•
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar ye !
exceed$17,000? G/,
Yes ❑ No ❑ Yes Xo
Taxingdistrict Keynumber/Legal description Record number contract Pee number tP ( ) 9 ( )
0 28 - 2 6-11-12--Zoe -D oz. .6 47--ow'
I/We certify under penalty of perjury that the above and foregoing information'is true and correct.
Signature of appli Address of applicant (number and street,city,state,and ZIP code)
q s 63 fnn1\ s-- (21.1r, �� �,) 6
_sau...<...e..1
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
1