Disabilty_Hayes �f ,Q APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R13/1-20) CO't
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 propeity 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)
Is applicant the sole legal or equitable owner? If No, at is his/her exact share of interest? If o with someone other than spouse,
indi to it om:
es No
If name on record is different than that of applicant,indicate below: 44/?'
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Name of contract seller GfQSOAi Co,,q
1 AVO/
Address of contract seller(number and street,city,state,and ZIP code) Is the p perty in question:
[.'Real 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)?
VX)UL./ , ❑Yes ❑ No ❑ Yes ❑ No
Is the property used and occupied primarily forhis/her'residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000? •
• Yes ❑ No _ ❑ Yes ❑ No
Taxing district Key number!Legal description Record number(contract) Page number(contract)
PrIA v\c > C%12— It -ca-. 3-DOI . 1-5-1 -Dab .
I/We certify under penalty of perjury that-the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
u29.--- 30
ign re of auth rued representativ Address of authorized representative (number an street, ity,state,an ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS •
Name of applicant Date filed(month,day,year)
ar �s . FILED
Name of contract seller r�
MAR 8 2021
Taxing district A
Key number/legal description GIBSON COUNTY AUDITOR
00 . 41i -oar .
Signature of County Auditor Date signed(month,day,year)