HomeMy WebLinkAboutDisabilty_Patterson� I°'" APPLICATION FOR BLIND OR DISABLED PERSON'S
.;, - � DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R / 9-96)
y� � Prescrihetl by Ne Sute Board of iar Commissioners
i orthation contained in this documeni is CONFIDENTIAL pursuant to IC 72-1-1-7(n) and IC 6-7.1-72-72(b).
INSTRUCTIONS FOR FILING:
To be liled in person cr by mail with the County Auditor ol the counry where the property is loca-
ted during the i2 months be(ore May 77 0/ the year the deduction is to be e!(ective.
See reverse side (or additional instructions and qualilications.
ime of applicant (owner or cantract buyerJ � �G�
� �� �
applicant the sole legal or equitable owner? It No, what is his/her exacl share of interest?
✓�Yes ❑ No
name on
contract
Address of contract seller
as
QN�s ❑ No
property used and
❑ Yes ❑ No
1
as
excee�$7
b
COUNTV I TOWNSHIP
DEC 20 2000
I with someone
with whom
YEAR
spouse,
t disabieo and unabie to engage in any substantiai g;
in IC 6-1.1-72(d)? �-'�e5 ❑ NO
gross
❑ Yes
year
I/We certify under penalty of perjury that the above and foregoing informalion is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 7, 19 �
at e of applicant � Signature of authorized representative (by executed Powe� ofAttomey)
� �!. �._a.r�. '
M , i e � A/ I I A n w w i �i �
Address of authorized representative