Disabilty_Tobe 1 t
57�-,;•;,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
*If State Form 43710(R13/1-20) I b5on (�q(�t� ]
Prescribed by the Department of Local Government Finance `J
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
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
spouse.
indicate with whom:
U./re-5 ❑ No
If name on record is different than that of applicant,indicate below'
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the pro erty in question
eal 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)?
t, '<s ❑ No Ems ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000"
ges ❑ No [s No
Taxing district I Key number/Legal description Record number(contract) Page number(contract)
"`o c7► r y GQ(0 0(p— 300—00 y Lfo 0.2
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)
�
707 i3.1-4-neir Ow6s ►��e. -J1V '1766 c
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ignature of aut zed representative ' Address of authorized representative (rrdmber and street,city state.and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant Date filed(month,day year)
ei- d L' l o b.2
Name of contract seller FILED
Taxing districtFEB 21 2024
st
/ " \0v\-.k-govN1Pr5 Key number/legal description AcAstiC
1 GIBSON COUNTY AUDITOR
Day yob- pa
Signature of County Auditor ✓�� Date signed(month,day,year)
jas,
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You are entitled to monthly disability benefits.
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