HomeMy WebLinkAboutDisabilty_Hartley� _ _ .
/� °'" : APPLICATION FOR BLIND OR DISABLED PERSON'S couNTr TOWNSHIP vea,R
�, DEDUCTION FROM ASSESSED VALUATION ��
� � State Fartn 43710 (R6 / 4-04) /C�
'•� Prescribed by the Departmeni of Local Govemment Finance
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In atlon contained in this document is CONFIDENTIAL pursuant to IC 72-1-i-1(n) and IC 6-1.1-�2-12(b). File Mark
li�!CTIOMS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May if of the year the deduction is to 6e ef(ective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months before March 2 of each year the individual wishes to
o6tain the deduction.
See reverse side for additional instructions and ualiFcaGons.
Name of appliwnt (owner or contract buyerJ
� ��
Is applicant the sole legal or equitable ovmer? If No, what is hisRie exaU share of interest? If ovmed vrith wmeone other than spouse,
indicate with whom
5 ❑ No
If name on rewrd is difterent than that of applicant, indicate below
Name of contrad seller
Address of wntrad seller Is the property in questlon:
❑ Real Property ❑ Mob1e Home (IC 67.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1. i-12-12(b)? Is applicant disabled and unable to engage in any substantlal gainful acfivity
� as defined in IC 6-1.1-12-'11(d)?
❑ Yes ❑ No es ❑ No
Is the property used and occupied p� for hislFier residence? Does the appliwnYs taxable gross inwme for fhe preceding calendar year
exceed 577,000?
es ❑ No O Yes �
T g distnct Key number / Legal descriptlon Record number Page number
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I/We ceAify 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 t, 20 _
Signature of ap liwnt Signature ot authorized representative
Address of applicanf . Address of auihorized represeniative
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