HomeMy WebLinkAboutDisabilty_Haubold'°"' APPLICATION FOR BLIN OR DISABLED P SON'S
r - ; DEDUCTION FROM ASSE
S- State Fortn 43770 (R6l d-04) . -.
'•�• � Prescribed by ihe Department of Local Govemment Finance
COUNTY TOWNSHIP Y£AR
s
Ir` ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-t(n) and IC 6-1.7-12-�2(b). File Mark
���ucriorvs: MAY 1 0 2005
7o be filed in person or by mail with the CountyAuditor of the county where the property rs /ocated.
Filing Dates: 1) Real Property: Dudng the 12 months before May 11 of the year the deduction is to 6e eNective. �-y�'
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each year the�iir�NiQu�s to
obtain the deduction. G�gSON COUNTY AUDITOR
See reverse side for addrfional instructions and oualifiratinns
of applicant (owner or conVact buyerJ
or
name on
of contract seller
No, what is hisRier
Yes ❑ No �
that of applicant, indipte below
share
If owned with someone other than spouse,
indicate with whom
Is the property in quesUon:
:eal Property ❑ Mobile Home (IC 6-1.1-
licant blintl as tlefinetl fn IC 12-1-1-1(n) and IC 6-1.1-72-12(b)? Is applirant disabled and un�ble to engage in any substantial gainful activity
as defined in iC 6-1.1-12-'I1(d)?
❑ Yes ❑ No ❑ Yes ❑ No
property used and ocwpied primanly tor his/her residence? Does the applicant's Wxable gross income for the preceding calendar year
' exceed 517,000?
( Yes ❑ No ❑ Yes ❑ No
I djqtrict
� �- �
I/We certify�under penalty of perjury that the above and foregoing information is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of authorized
6 appuc�ajn[ ' � Address of auNorized
� / V _ , ���