Disabilty_Fultz R,=.,, APPLICATION FOR BLIND OR DISABLED PERSON'S �•�•�l,�r •" YEAR
�i �� DEDUCTION FROM ASSESSED VALUATION
s`� i�f State Form 43710(R13/1-20) A �' 2A4022�2� ��2
'''' !'.''' Prescribed by the Department of Local Government Finance 3
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. a .l�l�
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the pri:Wt9 % ay,NTY AUDITOR
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)
ap )
Is applicant the sole legal'or equitable owner If o,what is his/ r exact share of interest? If owned with someone other than spouse,
��cc indicate with whom:
Yes ❑ No
If name on record is different than hat of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street,city,state.and ZIP code) Is the perty 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)? Is applicant disabled and unable to gage in any substantial gainful activit
/ as defined in IC 6-1.1-12-11(d)?
El Yes LFNo Yes El No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar r
� � exceed$17,000?
,r Yes ❑ No El Yes o
Taxing district Key number/Legal description Record number(contract) Page number(contra
a7,- 0
�`�f a G -/7-D/ - ypa - o0/. 9°a _o A,i
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Sre of applicant
�/ l Address of applicant (number/'and street,city,state,and ZIP code)
Signat
a.�- 71 - J K-d go'� l"V, � B.0„......L..4....a/&_ /11/ '/77 6-5
Signature of authorized repr ntativ Address of authorized repre entative (number and street.city,state,and ZIP code) )
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name ofplic
Date filed(month,day.year)
�
apJpant
V ;f Q
Name of contract seller FILED
Taxing district AUG 2 9 2022
,z2--e-ti•-(31
Key number/legal de iption Azt.,/et.e/ a ��
a -/ 7 -D/ -L/o d - oC l • 9 ° o _0 '( / GIBSON COUNTY AUDITOR
Signature of County Auditor ^ Date signed(month,day year)
M7
Notice of Award
0001157 00007250 3 MB 0.515 01312MCCTR7PB T41 P7
rVIVIAN K FULTZ r