Disabilty_Michel Jr r .a-- APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
� .4 DEDUCTION FROM ASSESSED VALUATION (((���
f'! c.'% State Form 43710(R12/10-16) /�•
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`a I Prescribed by the Department of Local Government Finance Iv 11 Vr�h 1 - \ \ -
Information contained in this document is CONFIDENTIAL pursuant to IC 61.1-35-9. v1C J File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant owner or contract buyer) t3 ��
� f� dv •
Is applicant the sole legal or.jim�\� If No,what is his/her exact share of interest? - If owned with someone other than spouse,
indicate with whore:
Yep ❑No FILE
IL II)Ii name on record is different than t applicant,Indicate below-.
Name of contract seller FEB- 8 2019 ,
Address of contract seller(number and street,city,state,and ZIP code) (,o • AUDITOR
•Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Is applicant bind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)? ,,,...,,,{{{
ID Yes No its ❑No
Is the property used and occupied prima*for h idence? Does the applicants taxable gross uuane for the ding calendar year
��// exceed$17,000? ����,,,,////
LJis ❑No [ Yes 0 No
Taxing district �� �� Key number I Legal description O aRecord number( �) Page number(mntrac°
Q NARS1 Ct� ()XL-\L—o 2 -301-003.1gs
I/We certify under penalty of perjury that the above and foregoing information is true and correct. I
Signature of applicant'f , n/� Address of applicant (number and street,city state,and ZIP cSde) P ,/�
�.�] tint itho ed!i'idl f �of authorized u representative (number c�:state,arn17Jp i) 1 '� �� �`
Signature of a represents' Address