Disabilty_Zerr .Mfg APPLICATION FOR BLIND OR DISABLED PERSON'S r COUNTY TOWNSHIP YEAR
,1:4. :,. DEDUCTION FROM ASSESSED VALUATION
j' State Form 43710(R13/1-20) I3OJ3kcL
Local Government Finance O�I
�eie
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)
UILvgUe1Ine tri/, e Zerr
with whom:
es ❑ No '
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(dumber and street,city,state,and ZIP code) Is the pr in question:
eaI 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 E—IC o es ❑ No
Is the property used and occupied primarily for his/her residence? ' Does the applidant's taxable gross income for the preceding calendar year
-exceed$17,0,00?
es ❑ No - ❑Yes 2 No
Taxing dis c Key number/Legal description Record number(contract) Page number(contract)
r��e� i� -- 210•-lA ,o8 - /a4-1�3-2z,5 -a2 -g
I/We certify under penalty of perjury that the above and foregoing information is true and'correct.
Si ature of applicant Address of applicant (number and street,city,state,and ZIP code) �-
y1..0.Lipe „&wi, _ / /fl r�acb'�.�V47WSi rauthorized representative Address of authorized representati (number and street,city,sta ,and ZIP code)
J
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Namee of applicant Date filed(month,day,year)
QVa C 6 e.A...,u_. ju
Name of contract seller FILED
Taxing dist'ct
JAN 0 5 7021
Key number/legal description AC-1ucte CGa J/Y d) }
26, , /�^L f- to Li-
i- CO3- _15- GIBSON-COUNTY AUDItOR U
Signature of County Auditor Date signed(month,day,year)
Ae-Ac,ei glituts t 5/aoa-1