Disabilty_DavisI
APPLICATION FOR BLIND OR DISABLED PERSON'S
— . DEDUCTION FROM ASSESSED VALUATION
• � Sfala Form 43770 (R9/9-OB)
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Prescnbe0 DY �e DepaM1menl H LaW Gmert�ment Frence
. �Nom m�taineC in tNS Aoaiment is CONFIDENTIAL pursuant W IC 6-1.7-12-12(b).
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MAY 2 5 zuw
To 6e filed in peison w by mail wHh the Cwx�tyAutlita ol the county where tlre piopeiiy is bcafed.
Fdirg Dates: 1J Real PropeRy: Durirg the year (w whirh the deductim is sotgAt.
2) AbG1e Homes assessed uMerlC 6-f. f-7 or Manulactured Homes nW assessed as Real Pruper(y: (�i
Mamh 31 W each year the individual wishes to obfein fhe detlucfidi.
See reverse sde Ioraddeional insWGions ana qua�ifications. GIBSON
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a,�a :�re or w�r.
u rema m recore
Nania d canlrad se�ar
No
and sWM �1: sbh�. and LP mdo)
Ls app6mnl bGnE as Ae6neE in IC 12-7-2-21(1)?
❑ Yes
Ls Cie wW�M usea antl «wdeC P��Y �
districl
f@948fICB�
❑ No
months be/pe
If owneE wilh someorre dlrer Nan sGW se.
iridimte with whom
Is Ne AWQM in West'vc
❑ � ��v � ,o.v*,ay' ws�a
n�to6ae Hm,e Qc s-t1-7)
6 appiimN disableE aM unable to e�yage in arry wbstaNial gainWl adivdy
as defined in IC 61.14241(C)?
�es ❑ No
�OBS ii1B 2CO�Ka(11'S Idz2bIC 9fO55111W11C �Ol I11B P�NB(��VIQ f2�Bf1�2f y8N
ezrsed 517,000?
❑ Yes nA No
Key number / Legal Aesaiptbn I Recwd numbar Paga nuniber
�6-1 a- �� 30% bao.56 �-oa�
17We certify under penalty of perjury fhat lhe above and foregoing information is true and wrrecl and that the applicanl was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20 _
mprese�Wtive
ndaress of �rxam (rpmber arM strcel, crty, slatc. and ZIP m,d�ej .
'o `���! I,�J. CQcar�%a� /`�'C //�x.t.t�",av> Z/�1 Y7G
AGEressolauflroriretlrepesenlative (nwnDaruar�dsbcel.cRy.slaro.anOLPCOOU)