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APPLICATION FOR BLIND OR DISABLED PERSON'S courm rowNSF+�a reaR
DEDUCTION FROM ASSESSED VALUATION
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� are��d ey u� o�ro„mn m �orai �t F.,�
Infomiation contained in Nis dowment is CONFIDENTIAL pursuant to IC 61.1-�2-12(b). � �
�"'�TRUCTIONS:
�meer�pers��by�a�rnn,ec�nrya�eao.arma�.����u,aa�aenr�a�rea. JUL 23 2012
Fwrg Dates.' 1) Real PropeRy.' Durfr�J Me year (or which the deduUion is sotght
2J Mobde Homes assessed underlC 6f.1-7 w Manufactured Homes not assessed as Real ProperqcOarfn�e (12) moNhs befora
March 3f ofeach yearlhe individual wishes to o6tain Me deduction. �l c\
tJame aiapplkant lowrreforoonaaa b+ryed
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It N0. wha[ �s hislher exeG
❑ Yes ❑ No �
rc rome on remra h ainmem aian mat ot appe�nt h,eicare oebw
se9er
arNSVeet �1: state,
LS aPP�t EOM az defined N IC 12-7-2.21(1)?
❑ Yes ❑ No
h Ihe MoP�Y uxd mM ocwpied P�1Y ta hialher rc
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KeY munher! Lepai dcsu�tim
H owned wiTh saneone other tlian spouse�
'uWic-ete wah whom:
�Is� M{e�g�W��M1y m W�m: ^,�,�1y�.I
U ��ca' Pf�Y ❑ ^°'�'f �
it�� �Ii1C �C. CY�.
ls a{pfxant d�sa6led and unaDie tn engage in any substanGal gairdW adMty
as tlefu+etl in 1C 67.1-12-11(aYr
-� Yes ❑ No
Does tlie apQfimnYa ta�mble g�ms i�woma (or tlfa premdirg cabrdar year
'1 a-�S-zo�- o o�. � aL -oa
❑ Yes ❑ No
RecaA m�mher Page manber
UWe certify under penalty of pe�jury that the aDove and toregoing information is We and cortecl and that the app�icant was a resident
of Indiana and owner of the aforementloned property on March 1, 20 _
SignaWre of applt�t AdE+ass of appBram (lwmber aM shee4 �3: �e, and ZIP oode)
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