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. APPLICATION F R BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
-�,`:� DEDUCTION FROM ASSESSED VALUATION nn., f((
_rP State Form 43710(R13/1-20) .1� I fC l} 2„
b\ = Prescribed by the Department of Local Government Finance 3L.SC)' ` U 1 1
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
Name of applicant(owner
contract buyer) c � A �,
U\
Is applicant the sole legal or equitable o ner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
. Yes D No
If name on record is different than t applicant,indicate below:
•
Name of contract seller
Address of contract seller(number and street,city,state,end ZIP code) Is h operty 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 a gage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
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 calen r r
'exceed$17,000?
Xes ❑ No 0 Yes L�No
Taxing district Key nu er Legal description Record number(contract) Page number( nt ct)
0OCt . 2...6 - °i
� -S1 -30o_ 000.L-k0A-00ck
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)
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Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of a— cant
Date tiled(month,day,year)
C.. 0)\ eV _ FILED
Name of contract seller
DEC 16 2021
Taxing district cy)_
GIBSON COUNTY NuutrOR
Key number/legal description /��'�j
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Signature of County Auditor ��� date sigrt(rd(mo ,day,year)
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