Disabilty_Ritchie��"'>41 APPLICATION FOR BLIND OR DISABLED PERSON'S uwTV r sH r�
_. DEDUCTION FROM ASSESSED VALUATION a �
'� State Form d3710 (R7 / S-O6) �.J � ..
Presaibed by 1he DepartmPni o( local Govemmeni Finance
nfortna�ion con[ained in this document fs CONFIDENT�AL pursuanl to IC 12-1-7-7(n) and IC 6-1.1-12-72(b). MAR e ark
INSTRUC7/ONS: /1�/''
To be (iled in person or by mail with the County Auditor ot the county where the pioperty is locafed. ��7( N��"�h
Filing Dates: 7) Real Property: Dunng the 12 monfhs be(ore June 11 07 fhe year the deduction is to 6e effecti v
NTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months belore March �3iB£�iii �E r the �nd�vidual wishes to
obtain the deductioa � ^ , _ . ,_.,
See reverse sidE
Name of appl(ic'a'�n
1
Is applicant the s<
If name on rewrd
Name o( mntract
(owner or conVact
of convact
legal or
❑ Yes ❑ No
ihan that of applicant,
exacl
s�.�
If owned vrith someone
indicate vrith whom
Is the property in quesGan:
spouse.
Property ❑ Moble Home QC 6-1.1-7)
Is applicant blind as defined in IC 12-b7-7(n) and IC 6-1.1-72-72(b)? Is applicant disabled and unable to engage in any subsWntial gainful activiry
, as defined in IC 6-1.1-12-'i�(d)?
❑ Yes ❑ No es ❑ No
Is Ue pmperty used and occupied primarily (or his/her residence? Does Ihe applicanPs taxable gross income (or the preceding calendar year
. exceetl 517,000?
❑Yes ❑No ��5 � �Yes �No
Ta�ti istrict Key number / Legal description Rewrd number Page number
a.c�-� _ _�--30�1:,o�a: �s�:� =
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 7, 20 _
of
1
authorized representative
Address of authorized representative
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