Disabilty_Doemer (2) . ,*. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
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400 DEDUCTION FROM ASSESSED VALUATION
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3F � State Form 43710(R13/1-20)
�'' Prescribed by the Department of Local Government Finance i3�A 00 \ 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 a i iG. or postmarked b •- ,lowing January 5 of the calendar year in which the
property taxes are first due and payable.
See reverse side for additional instructions and qualifications. 6 Ak
Name of applicant(owner or contrac buyer)
Inrn 1 0 e-i\f)ev
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Is applicant the sole legal ore equitable owner? If o,what is his/her exact share of inte s "s 'Tgo ith someone other than spouse,
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.1 di to i whom:
I Yes ❑ No
If name on record is different than that of applicant,indicate elow:
DEC 10 2020
Name of contract seller
GIBSON COUNTY AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) Is the prop in question:
eal 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?
es ❑ No ❑Yes No
Taxing district
Signature of applicant Address of a licant (number and street,city,state,and ZI code)
UN\NrS) .-`1-5N-5`(\& --- Lik) 4 s Itoo 0 1 cA,
nature of authorized representative Address of authorized representative (number aid street,city,state,and ZIP code)