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APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP ' YEAR
� ' r� DEDUCTION FROM ASSESSED VALUATION
r .;,lf State Form 43710(R13 I 1-20) 1
` . 0 70(8i
� Prescribed by the Department of Local Government Finance � .
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. \
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Name of ' ant(owner or contra uyer)
Is applicant ole legal or equita er? 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 applicant,indicate below: 1EI E r_ ".
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Name of contract seller
DEC 13 1024
Address of contract seller(number and street,city,state,and ZIP code) Gfi,,ji l s the property in question:
GIBSON COUNTY AUDITOR [ 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 definedin IC 6-1.1-12-11(d)?
[ Yes No Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cale dar y r
exceed$17,000?
es [ No ❑ Yes No
Taxing district , Key nu er I gal description Record number(contract) Page number contr ct)
0 2........_
a-\71-\00- 001 . -10 -ocri- . ,
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signa a of plicant Address of applicant (number and street,city,staattte,,mandd ZIP codve)�`
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ature of authori ed represe tive Address of authorized representative (number and street,city,state,and ZIP code)
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.... DAVID L FERGUSON 2
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--. 5831 DANVILLE DRIVE 0
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EVANSVILLE IN 47720-6903 T
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... We found that you became disabled under our rules on May 24,
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