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��•°'" t APPLICATION FOR BLIND OR DISABLED PERSON'S couNTr TOWNSHIP vEna
O DEDUCTION FROM ASSESSED VALUATION n
i'
SWte Form a377o (Ra / 70-07)
S��' Presaibetl by Ne Department of Local Government Finance
I�',rmation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). File Mark
�RUCTIONS:
0 6e filed in person o� 6y mail with the County Auditor ol the counry where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 17 of the year the deduc6on is to be eflective.
2) Mobile Homes assessedLnder IC 6-1.1-7: Behveen January 15 and March 31 oI the year fhe deducfion is to be e/fecfive.
See reverse side lor additional instructions and qualifications.
Name of ap ' t(owner or contract buyerJ
�
Is applicant the sole I�equitable owner? It No, w is hislher ezact share ot inieresi? If owned with someone other than spouse,
/�� indicate with whom
L�Yes ❑ No
If name on record is different than that of applicant, indicate below
Name ot contract seller
Address of contract seller Is the property in question:
❑ Reai Property ❑ Mobile Ho pC G7.1-�
Is applipnt blind as defined in IC 12-1-7-1(n) and IC 6-i.t-12-12(b)? is applicant disabled and unable to engage in any substa " gaintui aaivity
_ as defined in IC E7.7-72(d)?
O Yes ❑ No es ❑ No
Is Ne property used and occupied primariy for hisRier residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
� ❑ Yes ❑ No ❑ Yes ❑ No
Taxing district Key number / Legal desaiption Record number Page number
- a �o -�
I/We ceAify under penalty of perjury that the above and foregoing infortnation is true and wrred and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
�gnature of applicant Signature of authorized represenlative
�
Addr of applin Address of auNorized reD�sentative
/