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APPLICATION FOR BLIND OR DISABLED PERSON'S
. : DEDUCTION FROM ASSESSED VALUATION
� Stab Fam a3710 (R9 / 9-OB)
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Piasuibed Cy Uie Oeparimem d loml Go�ernmenl Fnarra
u
�ormatiom m�fained in [his Codiment is CONFIDENTIAL pursuant to IC 6-1 1-12-12(b)
COUNTY TOWNSHIP YEAR
_ . . . �����Maric
WSTRUCTIONS: �
To be filetl in person or by mail with the CountyAuditw o7Ure county where fAe property is locat
Filing Dates: 7) Real Prtperty: Durirg the year for whch the tleduction is soughG
2) Mobile Hanes assessed untler IC 6-7.7-7 w Manufactured Homes nof assessed as ReahRpoe�y: titr7rnv the IweNe (12) mm1As be7ae
Ma�ns�aaea,Y�.a,a;mMe�i�n��ooe�r�r�aaaa�. �irn c, c�' �r
See reverse stle la addifional insWdions ard aualiAcafions
Name d aPW (rnnm o� conbxt bv�eQ /y�Elil�" �%d+*� N�
`�.1G QIH90N COUNTY AU91T9R
Is appficam 5da legal or equitade owneR M No, is hisTher exaa shara of "unaresYl tl awried with someorie aher lhan spouse,
indimte vri�h wMm
Yes ❑ No
tl name m rernd is EiflereM Iha Ihat d appGrant irMimte bebw:
Nama ol cm�2d se�ar
AEdrasS ot mntratl m0er �ium�brJ and sbnM. tiq: ffi4. and LP mde) � qppe`(y � wgy�;
rt�Rop�ty p e��eynsse�a
� �nobae �iortie (IC s-�.�a�
Is applicam bGna as dafined in IC 12-7-2-21171� Ls appiont disableG antl una0la w eigaga in arry wbsamial gaiMul aaivay
as defin¢d in IC 67.1-72-77(d)7
❑ Yes No ❑ Yes ❑ No
�s a,e aweM �uea ane om,a�e v��N � n�. Bseexa? Dces Ihe aDWitaN's laxable 9mss iricwna for lha V eceCirg calen0ar Year
e�e sn.aooa
Yes ❑ No ❑ Yes No
Tasing d'a ' ` Key wm0er I legal tlesaiplion Recvd numbar Paga rumber
�7�� �- -O� 3�3-�a.7o3 0 �
IIWe certify under penalty o( perjury that lhe above and foregofng information is true and covec� and ihat the applicant was a residenl
of Indiana and owner of lhe aforemenlioned property on March 1, 20
Signature N appl'vnt Add2ss of appF�ant (monOrrantl street. pry, sfate. an0 ZIP mtle)
1� �/� c�Cl o�� � -�
' a1u2WauNOrizeErapresenU4ve P4eressotauthonzedrepresentaWe (numJrlandsLectcity,sfate.an LPCOde) "