Disabilty_RobbAPPLICATION FOR BLIND OR DlSABLED PERSON'S cou►+rv rownsa�a rEar�
r-- DEDUCTlON FROM ASSESSED VALUATION -•- ��
,� � , srafer�mc+»otasisosJ �
Prr.,amed by tne Deparorent of Lma� Govemment Fkiarke
Infortnation contained in this document is CONFIDENTIAL pursuant to �C 6�.1-�2-12@). F� ��
�ucnoNS: MAY 4 �
filed in person or by mail wdh tlre CountyAuddor of the county where fhe property is located. C.'J.
Fr7ing Dates: 1) Real PropeRy. During the year7o� which the deduction is snught
2) taobBe Homes assessed under IC fri.1-7 or ManufaCUred Homes not assessed as Real Properiy During U��a� nfhs befors
Mardr 31 oJesch year the individuei wisfies to obtain the deduction. G�gSON C�
See reverse side lnradditional instn�ctions and ualifications.
Name of aAWkant (ovmeror conhad buyeh
C � --
Is appOrant the sde iegal or e9uttable oxawl? If Na, wha[ is hiNher ezact share of interest? If awned with saneone otlrer tliari sPa+ge.
u�dicate xiN rf�an:
❑ Yes ❑ No
tt �ame an remd is a�meta aqn Na[ ol aaW�++l vwira[e cerow
Name oi mNrert se9ar
Mdress at con7aa seiler (memberar�d streeG dry sia[e, aM LP oode) Is 7�WenY in question:
A��v O �+�+�r�
rk�le �me pc Fr�.�-n
is zaa��i �a � dar�a � ic �za-zsi�ir is �t Q�san�a ana umae m e�e m a�v sucsw,�w s� �v
as In IC 61.1-12-11(an
❑ Yes ❑ No ❑ Yes ❑ No
h the propMY uxd eM oaupiad C���Y tor hisRar reside�e? Don Ihe aPP��rs ta�mMe 9� irkortielor Ma P�ecedin9 cebrdar Year
ex�ed E77.0007
❑ Yes ❑ No ❑ Yes ❑ No
d�iG� Key munher / Lepai dcsri�lion _ Recad m�mhet Pepe num6er
�/
� d — —7-IU —�
UWe certify under penalty of peryury that the above and foregoing infortnation is We and correct and that the appiicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
��ot a Atltlress of aPOGCa'n (numDerantl sGee4 �l: yate, aM oode
. �� w �,� ��
Sgranxe o! aW wrtred Address af sult�waed representetive (nambereM ciN. steta� antl LPCOde)