Disabilty_Pauley�""'"n APPLICATION FOR BLIND OR DISABLED PERSON'S cOUNiv TOWNSHIP � YEAR �
s;_ .. � DEDUCTION FROM ASSESSED VALUATION I
• ��� SWteFOrmd3710(R4/70-01) c
S �.tr"� Prescnbed by Ne DepaRment of Local Govemment Finance
I���rmation contained in this document is CONFIDENTIAL pursuant to IC 12-t-1-1(n) and IC 6-1.1-12-12(b). File� ��;?—� �
�RUCTIONS: �� �' � �
o be �led in erson or b mail with the Count Audilor of the coun where the ro e ' Fi �
p y y ty p p rty is located.
Filing Dates: 1) Real P�operty: During the 12 months be%re May 11 of lhe year the deduction is to be elfective. q��9
2) Mo6ile Homes assessedUnder IC 6-1.1-7: Befween January 15 and Ma�ch 31 of the year the deductio�'isrto�e1e/fe�tHvp.
See 2verse side for additional instruclions and qualifications.
Is applicant the sole legal or
If name on record is diBeren
Name of contract seller
4ddress of contraG seller
Is applicant blind as defined
owner?
❑Yes ❑No
than that of applican
H No, what is his/her
12-1-1-7(n) and IC 6-1.7-12-12(b)?
❑ Yes tG No
�..., .
G:8,9Ui�
1 � ,�Ip!
spouse,
Is the property in question:
JCF�ea� Properiy ❑ Mobile Home (IC E1.1-
Is applicant disabled and unable to engage in any substantial gainful aCivity
as defined in IC 61.1-12(d)? �
% Yes ❑ No
Is the property used and occupied primarily for his/her residence? Does Ne applicant's taxable gross income for the preceding calendar year
� exceed 517,000? ��
Yes ❑ No ❑ Yes .�No
district Key number / Legal desaiption Record number Page number
` � _ _ ^ _O'O�c� ��O V
I/We certify under penalry of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 .
.