Disabilty_Morrison"�_ " APPLICATION FOR BLIND OR DISABLED PERSON'S
d ? DEDUCTION FROM ASSESSED VALUATION '
• State Form a3770 (R / 9-96)
S,�„ � Presuibed by Ihe State Board ot Tar Commissioners
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����ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-t(n) and IC 6-1.1-12-12(b).
RUCTIONS FOR FILING:
To be liled in person or by mail with the CountyAuditor ol the counry whe�e the property is loca
ted during the 12 months belore May 17 0! the year the deduction is to be eNective.
See �eve�se side lor additional instructions and qualilications.
Name m appiiwnt (ownei or contracr buyerJ
� W M-�'� i r ,�:Clal%_WOL1 ��
Is applicant the sole legal or equitable owner. If No, what is his/h
Yes ❑ No
If name on record is ditterent than that of applicant, indicate below
Name of�trda 5eiler
I�
Address of co traci seller
Is applicant blind as defined in IC 7-7-t-1(n) and IC 6-T.lT2-i'f'(6j�
�Yes �,(do
Is the property used and occupied primarily for his/her residence?
��Les ❑ No Q
�strict . �ap�t-E�,;
1�c.� � � �O I �, —
exact share ot
�
COUNTY TOWNSHIP YEAR
File Mark
- F�� =��
MAY i 1 �4��
� � �.;,/� 1�n<�
f owneU with sorrieone other than spouse,
idicate with whom
- eao-��-�;
exceed
I tlisabled and unable to engage in any substantial gainful activiry
in IC 6-1J-12(d)? �es ❑ No
z-o7 �o/ -DO �. D7S�-d��'
o le gross incorLe. for the r edirg calendar ear
i 00Cc� , ��" `� �o ��'_� +o d7o 5�
-�oa I ; .:, ���. ..
I/We certify under penalty oi perjury ihat the above and foregoing information is true and correct and ihat 1
dent of Indiana and owner of the aforemeniioned property on March 1, 79 _
ure ol applicant �/ Signature of au;horized representative /bv exe
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Social Security Administralion
Nid-America P�o9ram Servi.ce Center
6QL East TueLftf� Slreet
Kansas City, MO 64106-2859
OFFICIAL BUSLVESS
PEN.ILTY FOR PRIVATE USE, 5300
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