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Disabilty_Ermling F T ED .�t—,, APPLICATION FOR BLIND OR DISABLED PERSONS COI TOWNSHIP YEAR "i DEDUCTION FROM ASSESSED VALUATION 7f ;;, tl'1 !"i' State Form 43710(R13/1-20) � / 2 \ A R 1 4 2022'. Prescribed by the Department of Local Government Finance Sfl vG�� "� Z. exile Mark Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. GIBSON COUNTY AUDITOR 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) Is applicant the sole legal or equitable owner? If No,what' his/her exact share of interest? If owned with someone other than spouse, indicate with whom: ❑Yes El No If name on record is different than that of applicant,indicate below: Name of contract seller Address of contract seller(number and street.city,state,and ZIP code) Is the property in question: Real Property El Annually Assessed Mobile Home(IC 6-1.1-7) Is applicant blind as defined in IC 12-7-2-21(1)7 Is applicant disabled and unable to engage in any substantial gainful activity as defined in IC 6-1.1-12-11(d)? Eg/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 Taxi/9-ict Key number/Legal description Record number(contract) Page number(contract) dG -'11-e if - fI0o-IOC) o . /99-ooz 7 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) 2< 71'2<Ae/ GJ z,-rr � X,(53/ 5 i©a v/ PR'/A/ 7 7 ///( il76,70 Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)