Disabilty_Martin (3),r!
1
' d9`�'" 4 APPLICATION FOR BLIND OR DISABLED PERSON'S TO 1 veaR
� ;1�1 DEDUCTION FROM ASSESSED VA�UATION
i �StaieFOrtnd3710(R7l,�i-W)
� Prewibed by Ihe DepaM�rnt N lotal Go+emmeni Fiwnce 008
� File Mark
nformation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-7.1-12-12(b).
INSTRUC710NS: �„„ ��
To be /iled in person or by mail with Ihe County Audilor oI lhe counly where the propeRy is located.
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Filing Dates: i) Real Property: During the 12 months before June 7 7 07 the year lhe deduction is to be ��� COUNTY AUDITOR
2) Mobile Homes assessed under IC 6-L 7-7: During the 12 months be(ore March 2 0( each year the individual wishes to
obtain the deducfion.
See reverse side for addrtional inslrucfions and ualifications.
Name of applic�nt (owner or contract buyerJ _
C/ C%?IG/v�./vC:/ 7 :iCiCIiC.['//f�C�./
the wle legal or equitable owner? � if No, what is his/her exaU
❑ Yes ❑ No
name on
of conVact seller
indicate beiow
I with someone other than spouse,
wi�h whom
Is lhe property in queslioo:
❑ Real PropeM O Mobde Home (IC G7.7-7)
applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-72-72(b)? Is applicanl disabled and unable to efgage in any subsWntial gainful activiry
as defined in IC 6-1.L72-�1(d)?
❑ Yes No Yes ❑ No
ihe property used and occupied primanly or hislt�er residence? Does Ihe appliwnCs taxable gmss income for Uie preceding calendar year
exceed 317,000?
Yes ❑ No ❑ Yes ❑ No
uing d�� �ct � Key number I Legal descripGon Record number Page number
�-V ti.,...� la �!d - 0 7- yol - D00. a�
IMIe certi(y 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
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Address of appGwnt
� 330 5. ,�
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:
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Signature o( authorized represenlative
auUorized