Disabilty_Rainey APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
a 4e DEDUCTION FROM ASSESSED VALUATION
}i,, l+ State Form 43710(R13/1-20) Gson 025 2022
��� , 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 property is located.
Filing Date: Form must be completed and signed December31 and filed or'� the following January 5 of the calendar year in which the
property taxes are first due and payable. W/�(^/ /'- , ^v
See reverse side for additional instructions and qualifications. V
Name of applicant(owner or contract buyer)
Rainey, Philip A
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? Ft ithiththan spouse,
w�ouY
lI Yes ❑ No L
If name on record is different than that of applicant,indicate below:
APR 1 3 2/022
Name of contract seller a 'q-_'`. _'
GIBSON COUNTY YYY///AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
II 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)?
❑ Yes 0 No ® Yes 0 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?
0 Yes ❑ No ❑ Yes ® No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
025 26-19-20-100-001.780-025
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
gnature of applicant
i KAddress of applicant (number and street,city,state,and ZIP code)
Ps ✓ ,,o f 462 E 800 S, Ft Branch, IN 47648
Signature of authorized representativ Address of authorized representative (number and street,city,state,and ZIP code)