Disabilty_Mason f = APPLICATION FOR BLIND OR DISABLED PERSON'S 14OWNSHIP YEAR‘
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) 1
-^✓' Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. V 3 V 20
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 thk iatek161 t fa1a:Kb'i c dar year in which the
property taxes are first due and payable. GIBSON COUNTY AUDITOR
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,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 different than that of applicant,indicate below:
Name of contract seller
CONTRACT
•
Address of contract eller(number and street,2fe,andPcode) Is the property in question:
Zeal 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 EA 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?
14.Yes ❑ No ❑Yes ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
3- 9 - !o al - two.SG &'_ 0.0 7
I/We certify under penalty f 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)
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Signature of authorized r presentative Address of authorized representative (number and street,cityr5tate‘,.,and ZIP code)
Notice of Award
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�'�'�= OAKLAND CITY, IN 47660
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