HomeMy WebLinkAboutDisabilty_Priestly""" . APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTV TOwNSHIP Yeo,R
� ; DEDUCTION FROM ASSESSED VALUATION
S State Fortn 43710 (R6 / a0a)
•'•�• � Prescribed by fhe Depanmeni of Local Govemment Finance �!
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t i6on contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-72(ti� ' File'Madc
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To be �led in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Rea/ Property: During the 12 months before May f 1 0/ the year fhe deduction is to be eNective.2005
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 0/ each year the individual wishes to
/� obtain the deduction. - �/
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�UDIiOR
or equitabl2'owner? If No, what is hisRier exact share of in res .� I( owned with someone other Man spouse,
indiwte with whom
�4$s ❑ No �
If name on record is diRerent ihan that of applicant, indiwte below
wnVact
Is the property
eal Property ❑ Mobile Home (IC 6-1.1
id as defined in IC 12-1-1-1(n) and IC 6-1.1-72-12(b)? Is applicant disabled and unable to engage in any substantial gainful activit
as defined in IC 6-1.1-12-��(d)?
❑ Yes ❑ No Yes ❑ No
used and occupied primarily for his/her residence? Does the applicanPs taxabie gross income (or e preceding calendar year
exceed 517,000?
es ❑No a�-�a -o� -ao - �a3, ��i0 ��Yes o
Key number / Legal descriptlon Record number P ge number
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IMle certify under penalty of peryury that the above and foregoing intormation is true and conect and that the applicant was a resi�Jent
of Indiana and owner of the atorementioned property on March 1, 20 _ .
_ � �J ISignalure of authorized representative
/ T/
ipplicant ' Atltlress of authorized representative
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