Disabilty_Dienhart in�T� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
A,. , DEDUCTION FROM ASSESSED VALUATION
:r
F,.,.0 State Form 43710(R1311.20) �� _ elk 0 0 ,
.;ir0 Prescribed by the Department of Local Government Finance
File Mar
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 0/S
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
it indicate with whom:
❑ Yes ❑ No
If name on record is different than that of applicant,indicate below: JAN O 2 2025
Name of contract sellerAze'izada. .ditt/24.)
GIBSON COUNTY AUDITOR
Address of contract seller(number and street,city,state,and ZIP code) Is t'i 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)? 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 es [ No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding cafeA<e
ar
exceed$17,000?
Yes ❑ No [ Yes kNO
Taxing district Key nu be I Legal description Record number(contract) Page number(con ract)
CO- 9-I4^-1- 20l-00i.36_ onl- .
IIWe certify under penalty of perjury that the above and foregoing information is true and correct.
S' nature of applicant Address of applicant (number and street,city,state,and ZIP cgde)iv ‘ ' 31‘k. CA)
8l s� 11 brikJI -1 "-)1
/ 44/11,Si ature o lhorized representative Address of authorized representative (number and street,city,state,and ZIP code)
MICHAEL G DIENHART
324 W OAK ST
OAKLAND CITY, IN 47660
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