HomeMy WebLinkAboutDisabilty_Myers°"" APPLICATION FOR BLIND OR DISABLED PERSON'S
. - . DEDUCTION FROM ASSESSED VALUATION
� Sta1e Fmn 43710 (R919-0B)
.� �
COUNTY TOWNSMIP YEAR
+ Preunbed by Me Depanmenl d Loml GrnertvneN F�wice
�formation wntained in Ihis dawment is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). � e
'"SrnU°no"S: JUN 6 2011
To be file0 in person w by mail wifh the CormtyAudifa o7the wunty where the poperly is bcated.
Filirq Dafes: 1J Real PropeRy: Dunrg the year lor whch the deduction is soughG C. �_
2) Mobile Hwnes assessed unAer IC 6-1.7-7 or Manufaclured Homes not assessed as Real Ropeify: Ounrg fhe e f 2) monNs befae
Ma�ch 31 W each year Me irdrvi0ual wishes to o6lain Ne deducUon. GIBSON
See reverse sAe for addd"anal insWctions and qua�ifications COUNTY q UDITO
Name of zGdiam (aw�xr m cm u bule�
\�ohn.o�'Yir�.en� 0�,�n�i�,�i S''�/iiDnn
� evosmm u� ��i m eowade ow,ren / 1 )I n r+o. �� t�m� e�u
tl�ma on `ecwtl is EiBatanl Man tlul ol applirant i(d'pafe E61o�r.
mCar (ru�mDer ad strvc{ ciry, sfab, aM ZIP mdo)
Ls appli�am b5nE az CeEned in IC 12-T-2-21(1�?
U Y05 '�"NO
61he G�M useE antl amipieE 0��1Y br �a/her rastlence?
1 es ❑ No
i some«�e ar�er
wtrom:
Is Ne pWaM in quesfian:
❑ �p�v ❑ n�ru,auvw�
Mohae Fbrne (IC s-1.
Is appimm diublad aM unabla to ergage in ary wbslaniFal gairdul atlivdy
as defined in IC 61.142-N(A)? �
ooes u,e avpwam•s
ezmeE 517,000'!
Key number I Legal desuiption
� 6-/d- 07-�fa/-�.
No
r year
❑ Yes �fd�
Rcrad number Page numDOr
IIWe certify under penalty of perjury thal the above and foregoing information is We and covecl and that lhe applicanl was a residen[
of Indiana and owner of the aforementioned property on March 1, 20
Signa�ura
AdOress ot applicaM (mmbeiarrdsbeet. crty, sWfc, antl ZlPwde)
AEEresso(aNlrorizedrepresentafive (nwn'sr(fdstreef,city,state.andLPCOde)
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