Disabilty_Deboard (2), APPLICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSHIP vEa,R
; ,"' DEDUCTION FROM ASSESSED VALUATION
� , StateFOrtn<3)70(RSl6-03)
�« prescriDetl Ey Me Department of Local Govemment Finance �
IN�rtnaSon contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1- b) Fil ark
UCTIONS:
i �e filed in person or by mail with the County Auditor o( the counry whe�e the property oc d. �Q3
Filing Dates: i) Real Property: During the 12 months before May 11 0/ the year the deduction i�qt ��ti .
2) Mobife Homes assessed under IC 6-1.1-7: During the 72 months before March oi each ye t��vid / l wishes to
obtain the deduction. /` /
See 2verse side /or additional instructions and qualifications. (/ `-�. 1 n❑
Name of appliwnt (ojvne or cont2ct buy4��/1 _ , �-. --onnt-COU�TY
No, what is hi�her exad share o( interest? __ J liowned wiN someone oNer than spouse,
❑Yes ONo I
on record is difterent than that of appliwn[, indicate below
bo�8 � gdthg'm rtn�J !- `.'v ``
IIWe certify under penalry of perjury that the a an fore fo ation is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
ignatur appliwnt Signature of authorized representaWe _
� � � ��/f� �
��/......r......e _ AAdrrsc nf authnri�od moresentahve :
/ / � � I�� '��