Disabilty_Robb (3) . 4 APPLICATION FOR BLOND OR DISABLED PERSONS COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R9I9.OB) F ILED
41-11 Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-f.1-12-12(b), Relied(
'gUCTlONs: Mpy
filed in person or by mall with the CountyAuditor of the county where the property is located. C .
Filing Dates: 1) Real Property:During the year for which the deduction is sought
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During t h. a )(t nths before
March 31 of each year the individual wishes to obtain the deduction, GIBSON 0
See reverse side for additional instructions and ualihcations.
Name of applicant(owner or contact buyer)
C1.5\_ &
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,
indicate with whom:
❑Yes ❑No
If name on record is different than that of applicank indicate below:
Name of contract seller
Address of contract seller(numberand street,city,state,and ZIP code) Is property in question
eal Property 0 AnnuallyAssessed
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)?
Dyes No El Yes ❑No
Is the property used and occupied primarily for hisiher residence? Does the
applica
D nt's!gable gross income for the preceding calendar year
exceed❑Yes No ❑Yes No
d' ct Key number Legal description Record number Page number
e'vLtpOr
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20
Sign re of appll nt Address of applicant (numberand street cry,state,and iF1code I
3
? /16074_
Signature of authorized repre rtative Address of authorized representative (number and ay,state,and ZIP code}
� 1
*** REC 2012124 142427 H9E721E0 F1TO ' CIPQYAC PQAC (F-DPO ) ***
(-7,'IAL SECURITY ADMINISTRATION
l
Date: May 3 , 2012
Claim Number: 317-64-0213A
317-64-0213DI
CARL M ROBB
329 W BRUMFIELD AVE
PRINCETON IN 47670-1353
)
