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Disabilty_Miller alp -aQ .M.,,, , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR °' DEDUCTION FROM ASSESSED VALUATION 7r� 44 Nit*. State Form 43710(R13/1-20) (^/ '+` �f' 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 -T Is applicant the sole legal or a uit le owner? If No,what is his/her exact share of interest? If owned with someone other than spouse. indicate with whom: 11,e ❑ No i If name on record is different than that of applicant,indicate below: ;'9 ^^ . ViS),.\ . Name of contract seller w\ ©J `' oc(0R Address of contract seller(number and street,city,state,and ZIP code) `j Is the pr perty in question: � jy��,tkt'lVV-' t Real Property ❑ Annually Assessed G' os- 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 No liPZ ❑ 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? V.:: ❑ No E] Yes No Taxing district Key number/Legal description Record number(contract) Page number(contract) I/We certify under penalty of perjury that the above and foregoing information is true and correct. Sign ure of applicant ,{rn Address of applicant (number and street,city,state,and ZIP code) k\ urere f zed epresentativ Address of authorized representative (numb-Er and street,city.state,and ZIP code) RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS Name of applicant Date filed(month,day,year) Namecontract seller 1 FILED Taxing district J�� '� JAN 0 5 2022 C ` Key number/legal description l - Ct - DoD - --kw a- 0 a GIBSON COUNTY AUDITOR Signature of County Auditor Date signed(month,day,year) �..�VN.o OA_ - c A,(--L / ( `—D 11.7 cP a .