Disabilty_Lasley (3)�
°'° , APPLICATION FOR BLIND OR DISABLED PERSON'S
; DEDUCTION FROM ASSESSED VALUATION
S State Fortn 63710 (R6 / 4-04)
� Presc(ibed by the Departrnent of Lacal Govemment Finance
COUNTY TOWNSHIP YEAR
� � � � �
�
In' tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). Y"'Fji�Mark� � �
ir�ucnoros: FEB 1 5 2007
To be filed in person or by mail with the County Auditor of the county where the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months 6elore May 11 of the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Dunng the 12 months 6efore March 2 of each yea�the_,individ'ual.wishes to
obtain the deduction. -
See 2verse side for additional instructions and ualifications. o�890N COUNTY AUDITOR
� Name of appliwnt (own or�ntlact buyer) (
�� appncant me sole legal or
name on record is difterert
ame of wntred seller
ddress of contrad seller
� appiicant blind as defined
Ne property used and occ
No, what is hislher
�j Yes ❑ No �
than that of applicant, indiwte below
❑ Yes
Yes ❑ No
If owned wiih someone oNer than
indicate with whom
Is the property in question:
Real Propert� � M�e Home (IC 61.1-7)
6-1.1-12-12(b)? Is appliwnt disabled and unable to engage in any subslantial gainful activity
as definedin IC 6-1.1-72-71(d)?
residence?
��O-id -o��- �-/03-00
/ number / Legal description p?/ .�/
�/9 -�/�`-%� �d
gross
0
❑Yes ❑No
rthe preceding calendaryear
g ❑ Yes
I/We certiy 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 _
authorized representative
mtlress ot applicant � Address of authorized representative
y�f E. 9✓� � �°��.�_i�.
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