Disabilty_Christy • .M4, •, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
A A DEDUCTION FROM ASSESSED VALUATION
s'1 State Form 43710(R13/1-20) �LNQ ) e22 '1 0`_
6-l';,,,--4:"it.. 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
3 0� 20c-2
Is applicant the sole legal or equitable owner? �,what is his/her exact share of interest? If eBne e4 se,
iQiIIIaSeCJRd,GSLkiNTY AUDITOR
Yes ❑ No
If name on record is different than that of applicant,indicate below:
Name of contract seller
ti S--
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question.
[1 RS' I 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 ILI-N ❑ Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed S17,000?
res ❑ No ❑ Yes ❑ No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
-Pp, $QJse_a_ 2 3-12-1 S-2-o-o- o o0.319--- 02-1- -
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)
KSig ature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed
(month,day.year)
Name of contract seller ;Al1 I L E D
DEC 3 0 2022
Taxing district
-P Vh.,.,5riJ< a. ila_i",?°14i)
Key number/legal description GIBSON COUNTY AUDITOR
IU) - ` -ls coo- uOO - ----- C -- --7
Signaatture of County Auditor _ /� /�a � Date signed(month,day,year)
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