Disabilty_Sisk �f-^•,•� APPLICATION FOR BLIND OR DISABLED PERSON'S
COUNTY TOWNSHIP YEAR
�.• DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R13/1-20)
Prescribed by the Department of Local Government Finance ( (bsb(A\ PNIN a �O
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
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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.
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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.
Iindicate with whom:
es ❑ No
If name on record its different than that of applicant,indicate below
et—
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the perty in question
Real 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 No ✓(Yes ❑ No
Is the property used and occupied primarily for his/her residence's Does the applicant's taxable gross income for the preceding calendar year
exceed S17,000?
l 7es ❑ No ❑ Yes No
Taxing district Key number I Legal description /f�('� 1 Record number(contract) Page number(contract)
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signet re of plicant t Address of applicant (number and street,city state,and ZIP code)
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Signature of authorized representative Address of authorized representative (number andity�,Ind ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
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Name of contract seller — - FILED
Taxing district
DEC 05 20239,
Key number/legal desc�( -N.0 �
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- `� ��(�O �� `� `- — c1�� 1 GIBBON COUNTY AUDITOR
Signature of County`Auditor v Date signed(month,day,year)
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You are entitled to monthly disability benefits beginning October 2023.
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