Disabilty_BeadlesAPPLICATION FOR BLIND OR DISABLED PERSON'S
. DEDUCTION FROM ASSESSED VALUATION
' '� j
Sfaffi Fmn 43710 (R9 i 9-OB)
Preunbed M' Ne DeGa��� d loW Govertm�enl F`w�ce
�damation containetl in Utis document is CONFIDENTIAL pursuaN to IC 6-1.1-12-12(b).
�
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COUNTY TOWNSHIP YEAR
ile
INS7RUCTIONS:
To be filed in person w 6y mail Kilh the CountyAUtlita o/ the oounty where Me propeity is located. JU L 1 3 ZQ ��
Filiry Dates: 1 J Real Property: Ounrg the year /a which fhe deduclion is soughL
2) Mobile Homes assessed uMer IC 6-7.1-7 w Manuladured Hornes not assessed as Real Roperty: Dunng the M BLh!BJ{�3�be
March 31 d each year Ne individual wishes fo obfain the deducGor�.
See ieverse si�e /m adddional insLudiorts aM qualificaGons �����.�.�—� �
jNameo(ap liram(owriermcmt�aclbuysrJ � �`��-"`��+��� T AUO
b
V[,J Yes LJ No �
H ruma m recad is GQererd tl�an Ihat d app6mnL iMi�ate Oabr.
d conitaU 9BOer
of anVad SBDer (mmbar an0 Sbaet �Y. sbb. aitl
as ear�aa �n �c i2-7-2-i��i7a
❑ Yes ❑ No
Ls Ne G��M useC aM ocwped P��' br �islhar resdeera?
❑ Yes ❑ No
m
ezad share o( i�rterast? tl o.med wtlh somea�a olher Ihan sGW se.
inCimte with wlrom
Key rumber / Lagal desmptian
3rry in Quehiort
��Y � ��Y�
AAo6de Hortie (IC 67.
b applimnt disaDleG an0 unaWa lo ergage in a�ry wbsfanlial gaiMUl atlrvily
a5 defined in IC &7.1-02-07(d�?
Does 1he appicam's lasade grnss u�cnma
azwetl 51�,000?
:. �/�,? _ /�OD. /S/-Qo2�
Remrd numbar
❑ Yes ❑ No
prec�edmg falariCar year .
❑ Yes ❑ No
Page numbet
IIWe certify under penally of perjury lhat Ihe above and foregoing infortnation is We and correct and thal lhe applicant was a resident
of Indiana and owner o( Ihe aforementioned property on March 7, 20 _
$igna�ure of appGCaN
Pddress of applimnl (nwribe! arM sbeel. cM. sfatc, antl ZIP cvtlo)
�( /�03 B�v�. �Cace PR „� c c T o��. �,� y�6r
AEErass ol aulhonzed repeseniatrve (nu.nDerantl sbee(, Uy, sfa(c, an0 LPCOOO)