Disabilty_Knapp"'" APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr TOWNSHIP vEna
DEDUCTION FROM ASSESSED VALUATION
` � Sia[e Fortn 43770 (RS / 603)
�� PrescriCed by Ne Department of Local Govemment Finance
Inf�.rnatlon contsined in this dowment is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-72-12(b). j� �( File�rkT(�
�:LCTIONS: � (� 'j `j--I �� i�
e filed in person or by mail with the Counry Auditor o/ the counry where [he properfy is located.� 11 �L.J !_.,/ �1�
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months before March 2 0l each.y�the �nd�d�al wishes to
obtain the deduction. „ . .
iee reverse side lor additional ins
Name of appliwnt (owner or contract
Is applicant the sole legal or equita [
name on recoN rs Gltterent tt
ame of contract seiler
ddress of conVact seller
�, applicant blind as defined in
'Qes ❑ No �
Ihai of appliwnt, indipte
_�_
❑ Yes
used and occupied prima
es
ie:en
❑ No
exact share of inlerest?
--✓-� , . i _=��.� � � ��
/,4'Gt,' -j _ .
' GI3SQNCuUNTr qWiiOn ,
If owned wiih someone other than spouse,
indiwle vriN whom
s the property in question:
❑ Real Properry ❑ Mobile Home (IC E1.1-7)
appiicant disabletl antl una
defined in IC 6-1.1-12(d)?
description
gross
engage in any substantial gainful activity
es ❑ No
ncome for the preceding cale/nd�ryear
❑ Yes L7No
i number Paga number
IM/e certify under penalty of pery'ury that the above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforemeniioned property on March 1, 20 _
� of applicant
"� V /
of applicant
30 9 s. se.�, �