Disabilty_Lemmons'�''� APPLICATION FOR BLIND OR DISABLED PERSON'S
- � DEDUCTION FROM ASSESSED VALUATION
State Form 63770 (R / 9-96)
�' � Prescnbetl by Ne State Board af Tav Commissioners
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I�ation confained in this document is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-1.1-12-12(b).
INSTRUC7/ONS FOR FILING:
To be liled in person or by mail with the Counry Auditor ol the county where the property is loca-
ted during the 72 months be/ore May i l ol the year the deduction is to be e)lective.
COUNTY TOWNSNIP YEAR
F M
/ �
�B 2 4 1998
See reverse side lor addifional instructions and qualifications. / �
Nameofapplicant(ownerorconhadbuyer) �y �;�.��
C`�p.�'�� COU!QTY' ,UDITOR
Is applicant ih�e rgal oi equita e owner? It No, what is his/her exact share of interest?. If owned with someone other than spouse,
indicate wiih whom
�es ❑ No
If name on record is ditterent than that of applicant, indicate below
Name of contract seller
Address o1 contraa seller
Is appiicant blind as defined in IC 12-1-1-1(n) and IC 61.1-72-12(b)? Is appliqnt disabled and unabte to engage i an substantial9ainful activiry
as defined in IC 6-1.1-12(d)? �e5 ❑ NO
❑ Yes ❑ No
Is the properry used and occupied primarily, for his/he� residence? Does the applicanYs taxable gross income for the preceding calendar year
ezceed $17,000?
❑ Yes ❑ No ❑ Yes o
Tauing district Key number / Legal descriptlon Record number Page number
-��-�. . .�(o--.��
I/We certify under penalty ot perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned property on March 1, 19
Signature of applicant Signature ot authorized representative (by executed Power olAttomey)
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Address of oap�plicant e/ ��� Address of authorized representaCrve
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