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°"' APPLICATION FOR BLIND OR DISABLED PERSON'S
-- DEDUCTION FROM ASSESSED VALUATION
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srare Fmn a�to �as i s oa�
� a�euwea nr ma oavan�a d i�i c�e�,� F�e
�Information contained in Ihis doaiment is CONFIDENTIAL pursuanl la IC 6-1.1-12-12(b).
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WSTRUCTIONS:
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To be Fited in person or by mail with the Co�mlyAudifor ol the awnty where Me properry is bcated. ��
Frli�g Dates: i) Real PropeRy: Ourng the yearlor which Me detluction is sought. L1�� �n�� \1
2J Mo6ile Homes essessed untler IC 6-1.1-7 w Manulectured Homes nof assessed a�a� rropeixy-�iiig`}�i��(12) monlhs before
Maich 37 W each year the irMirvitlual wishes lo obfain the deductipn.
See reverse side far addAbnal insWUions qualibcations
Nama aP N(owrerorcadr.-+4neA /ir Q
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Is aOVfim Ihe IaMe O�w�fs �-- ', wha� c s/her esacl shate d'urte�esl? C awned wdh aotreaie alher Ihan sV�+se,
iMimte wilh wfiom
❑Yes ❑No
tt n2me m reco�d i4 EiEaranl Nan tlwl d appRrant iMi�sfe bBbw.
Name of aritrarf se0er
ACdress d mnbad seAer (mmber antl stroW. Ul: stab. aM ZIP oo0a) Is Ne ptopetty in quBSfion:
R�IProperty ❑ anrx,atlyns�
. Mahde Horne (IC Et.t-7)
IS app&aN b5nE a9 deFned in IC 12-7-2�21(1)? Is applimnt disabled and unaEle �o eigape rti airy suhsWtlial gai(Aul adivdy
as Eefined in IG 61.142411d1Y
❑ Yes ❑ No � ❑ Yes ❑ No
k Ne propeM � arM ompied primarily br �isR�er ras0ance? Doas iha aPW�nfs taxada gross incorna br lhe p�ng calanCar Year
exmeE 517.000? '
❑ Yes ❑ No ❑ Yes ❑ No
�Tazi isvicl Key number / Legal desaiption Recortl numCer Page munber
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IIWe certify under penalty of pe�ury Ihat fhe above and foregoing informalion fs true and correct and Ihat the appiicant was a resident
of Indiana and owner of the a(orementioned property on March 1, 20
SignaturedappG�aM Mdressolapplimnt (rumbrraMSbeet.cM.sG�,a�tlZlPintlu)
� �_ � - 5 e na �' n�t �2 � s T
� ature d a zeC representalive Mdress ol aWhorized representalive (num�tr ard st2e.f, cGy, sfafe, aW LP code)