Disabilty_Hughes ,
<0;'- 4. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
;, '°i. _\,', DEDUCTION FROM ASSESSED VALUATION
"' State Form 43710(R1311 20) 1
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tifr
) a fl Prescribed by the Department of Local Government Finance ocicaLi,
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, �1
Filing Date: Form must be completed and signed by December 31 and filed orpostmarked bythe follows Jan,a d` e calendar
property taxes are first due and payable. �N� ryyear in which the
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
rocitivs..
Is applicant the sole legal or equitable o�"vne, 'It No,what is hls.'her ex r rest If owned with someone other than spouse,
indicate with whom:
❑ Yes ❑ No
If name on record is different than that of applicant,indicate below.
MAR 15 2024
Name of contract seller a��Z -
yhsu i n z d)
a
GIBSON COUNTY AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) I th property 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 a age in any substantial gainful activity
as defined in IC 6-1 1.12-11(d),
❑ Yes ) c). Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cale ar ar
exceed S17,000?
Yes ❑ No ❑ Yes No
Taxing district Key nu er egal description Record number(contract) Page number(contr t)
0 26-13-3Q -10\ -000.131 -00sr
1
IIWe 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)
)(a.
Signature of authorized repres ntative Address of authorized representative (number and street,city,state,and ZIP code)
.
SOCIAL SECURITY 3-15^a y px-N"
2300 N GREEN RIVER RD
EVANSVILLE IN 477154(t) ,00--(43-'6•--Q-1- 1