Disabilty_Donnelly-z. .' :
APPLICATION FOR BLIND OR DISABLED PERSON'S couHn TOWNSHI7 r�nrs
. . DEDUCTION FROM ASSESSED VALUATION �
• �- . � Sta�a Form 43710 (R919�08) �
�� s'
,• PresuiOeC by Ne Deparlmant tl Loml Gwaervn9nt Finarr,e
�iormatbm m�taine0 in Ihis Aoa�ment is CONFIDENTIAL File Mafk ' '��
pursuant to IC 6-1.1-12-12(b).
wsrnucrioNS: �'QN 1 8 2C11
To be filetl in person or by mail with the CountyAuditor o/ the county wf�ere tAe piq�erly is bcated.
Filirn� Dates: 1) Real Property: Dunrg fhe yearlw wh�ch the deduclion is sought. C•��
2) Mobile Hmies assessed uMer IC 6-1.1-7 w Manulactured Homes not assessed as Real Roperty: Dunrg the (weNe fhs before
March 31 d each year the irMivitlual wishes to o6fain fhe deduction. Q(
See reverse sitle IoraOddional insWCtions ard qualificafions �ON COUNTy qUD17QR
Name of zGG�N (ow�or or conbacf buyeQ ^
�
.a�
I5 applk�anl tha sda legal ar equi�aW6 owneR tl No, whai is histher e shara d i�rterasl7 tl owned wNh so(reme other Wn spoum,
iMimte wflh whom:
❑ Yes ❑ No I
n name on recarC i5 EiNamnl Nan Ihal tl appM'an� irdifale Oebxr.
Nartre d cantracl seoer
AOdress d mntretl 5e0er (numo�r aM sOnM, dry. stale. antl ZIP ooda)
Ls applimM bfin0 as OeFneE in IC 12-7-2-21�7 r!
❑ Yes ❑ No
Is Ne O�OeM �sod anE accvqed primarih/ br his/her ravdence?
e�smu
Yes ❑ No
_ //-/3-
r properry in a�es�ion:
RealProperty ❑ MrniauyASSessed
Nbade Flane (IC 61.1-�
Is applimN EisableC and unable lo e�gage in arry suEStan'al gain(ul atlivpy
as defined in IC 61.1-72-111E)?
❑ Yes ❑ No
Doas Iha apd�nt's larabla gross irimme br Ne preceding plen0ar year
exceeE 477.0007
i�o-6a�
number
❑ Yes ❑ No
II4Ve ceRify under penalty of perjury [hal (he above and foregoing information is true and covecl and [hal the appiicant was a residenl
of Indiana and owner of lhe aforementioned property on March 7, 20
Pddress of apptiaM (mm6(raid strcef, aty, safe, and ZlPmde)
/33� IJc�� u/in� f � � 7Cv �
represemative .�tlrassotauf"�� reprasentaWe (numbvandswcl,cify,slale,anOLPCode)
%�/'iivG �zf�N
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