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Disabilty_Besing `= 4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR �--; Y�••'•'`k� DEDUCTION FROM ASSESSED VALUATION State Form 43710(R7/5-06) /� 'J�` Prescribed by the Department of Local Government Finance 'r, j l-JI1\\() formation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n)and IC 6-1.1-12-12(b). File a '',formation NSTRUCTIONS: J U(_ 4 2009 To be filed in person or by mail with the County Auditor of the county where the property is located. Filing Dates: 1)Real Property:During the 12 months before June 11 of the year the deduction is to be..e ctive. 2)Mobile Homes assessed under IC 6-1.1-7:During the 12 months before March 2 of e cfflyear the idual wishes to obtain the deduction. GIBSON COUNTY AUI)ITO See reverse side for additional instructions and qualifications. Name of applicant(owner or contract buyer) g__ Is applicant the sole legal or equitable owne . It No,what is his/her act share of interest? If owned with someone other than spouse, indicate with whom ❑Yes ❑No If name on record is different than that of applicant,indicate below Name of contract seller Address of contract seller Is the property in question: Real Property ❑ Mobile Home(IC 6-1.1-7) Is applicant blind as defined in IC 12-1-1-1(n)and IC 6-1.1-12-12(b)? Is applicant disabled and un le to engage in any substantial.gainful activity as defined in IC 6-1.1-12-11(d)? ❑Yes ❑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? Yes ❑No ❑Yes ❑No Waxing district Key number/Legal description Record number Page number vd_rtyL../..A/1.4.e...iee. e? ?o_-a -_yam_o00 . © 00 3 I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident of Indiana and owner of the aforementioned property on March 1,20 _ Signature of applicant J Signature of authorized representative �r T Address of plicantAddress of authorized representative • �O r e v, I!_.2 .� LI7 (1,3