Disabilty_Johnson (2) APPLICATION FOR BLIND OR DISABLED PERSONS c UNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
1
''''..-.1.. . i State Form 43710(R13/1-20)
Prescribed by the Department of Local Government Finance '- e6() OU \ 11-3.-
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 contract buyer)
f\ck L3 a\n‘r\- u 'A -
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse.
Yes 0 No
indicate with whom:
If name on record is different than .at f applicant,indicate below:X
Name of,ect seller
23 1013
dress Jim
of contract seller(number and street,city,state,and ZIP code) Is th Reroapie Propertyr-ty in question: An
&tSON COUNTY AUDITOR Annually Assessed
Mobile Home(IC 6-1.1-7)
Is plicant 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)?
X II] ; Yes 0 No
Is the property used and occupied primarily for his/her residence? es No Does the applicant's taxable gross income for the preceding cale da ear
exceed 517,000?Y'es El No 0 Yes No
Taxing district Key n be Legal description Record number(contract) Page number co tract)
OM e)-C -I2_- o1-3c8-o ol.625 -bis
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
75ignature of applicant i Address of applicant (number and street,city,state,and ZIP code)
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ck4 --k 3 \AtI ik A N—6 f-% 3 1\J - 1.0- Gio .
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Signature of authorized re n ti Address of authorized representative)(number and street.city,state,and ZIP code)
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RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Fie ed(month .. , :iay.year) .
Cji\NIN .A1-4\ 7-) 0 .
Name of contract seller
.JUN 23 2023
Taxing district
0 iitg-
Key number I legal description GIBSON COUNTY AUDITOR
2- 6 - 11-01 --,S03 - 00 i 6 2 C-028-
Signature of County Auditor Date sign (month day,year)
f\MaiN1171 Z C 23 /7432 2 .
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