Disabilty_Sertich •
�MrST/14 APPLICATION FOR BLIND OR DISABLED PERSON'S SOUNTY TOWNSHIP YEAR
7; DEDUCTION FROM ASSESSED VALUATION
st ,i' State Form 43710(R13/1-20) q �o- 1 O / - (, C l i
''• Prescribed by the Department of Local Government Finance G-
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 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 is /her exact share of intere t? If owned with someone Cher than spouse,
T� indicate with whom:
❑ Yes ❑ No r ILT ■
If name on record is different than that of applicant,indicate below: �+ j�_"1J.L/
Name of contract seller `�\C1-5/ DEC 2 2022
aJ% 4 s the roperty in question:
Address of contract s Iler(nu er an st ee i ate,and ZIP code) GIBSON COUNTY AUDITOR
Real Property ❑Annually Assessed
�� Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in 16.'12- -21(1)? Is applicant disabled and unable to ngage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑ Yes o AYes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding talear
exceed$17,000?
Yes ❑ No ❑ Yes
Taxing district Key nu be /Legal{}ascription Record number(contract) Page numberA..-::o
ct)
0D\1--- Wb- 2k _ 4_I60 -op( .50 -c24- .
VWe certify under penalty of perjury that the above and foregoing information is true and correct.
Sig ure f applicant / ) Address of ap licant (number and street,city,state,and ZIP code) .
Sig ture of authonze repr ent ve /\`\ Address of authorized representative (number Ind street,city,state,and ZIP code)
009254