Disabilty_Hicks APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R13/1-20) G Sco
*6- --:� 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 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
If No.what is his/her exact share of interest? If owned with someone other than spouse.
indicate with whom:
LaXes ElNo FILED
If name on record is different than that of applicant,indicate below:
Name of contract seller MAY 1 3 200222� J_)
Address of contract seller(number and street,city,state,and ZIP codY)L:[G/ZtLc-C. l�Y '�✓ Is the property in question:
GIBSON COUNTY AUDITOR ❑ Real Property ❑ Annually
Ased
Mobile e(ICss 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 ((-N6 ❑"ems ❑ 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?
L�'Yes ❑ No ❑Yes ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
FrG.1C(5C 0 7113-17-3o3--OoO. OQ5
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)
(a nl -b—k 'Dr% S+- Frost c;sc o y7 oiq
Signature authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND I DISABLED PERSONS
Date filed(month,day,year)
Name of applicant
o...,-, p )-V L CY--s
Name of contract seller
Taxing
rdistrict FILED
Key number/legal description
-13-17-303 - 6 -c .C. MAY 1 32022
Date signed(month,day,year)
Signature of County Auditor
Aiftri
Yht �
OIDSON UUUN I Y AUDITOR
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