HomeMy WebLinkAboutDisabilty_Fears�'�'" t ar'�PPLICATION FOR BLIND OR DISABLED PERSON'S
/ , -•� ;', DEDUCTION FROM ASSESSED VALUATION
S , State Fortn 43710 (R6 / 4-04)
Prescribed by the Department oi Local Govemment Finance
COUNTY TOWNSHIP YEAR
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Iri�—afion contained in this documen[ is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-7.1-72-12(b). M
1l�JCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. A�n
Filing Dates: 1) Real P�operty: During the .12 months befo�e May 11 of the year the deduction is to 6e ef7L2Yive. s Z005
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each year the individual wishes to
See reverse side (or additional instructions and ualifiw6ons. �a ��j
IName of applicant (owner
— l, if ����
Is applirant the sole legal or equitable owner? I( No, what is hislher exaU share of interest? If owned vrith wmeone other than spouse,
indiwte with whom
s ❑ No
If name on record is diRerent than that of applicani, indiwte beiow
Name of cont2ct seller
— l�
Address of wn selier Is the property in question:
❑ Real Property O Mobile Home (IC G1.1-7)
Is appliwnt blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any subslantial gainful activiry
as defined in IC 6-'I.1-12-11(d)?
es No es ❑ No
Is Ne property used and ocwpie primarity r hislFier residence? Does the appliwnt's tauable gross income for the preceding calendar year
� exceed $17,000? �
Yes ❑ No ❑ Yes ❑ No
Ta�dng �s 'cl � Key number / Legal description Record number Page number
-O /S DO �C7
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ �
Signature of appf t Signature of auihorized representative
i� � � .
Address of app icant Address of authorized representative
�/a a �a.� t-