Disabilty_Shipman°"' APPLICATION FOR BLIND OR DISABLED PERSON'S r�aa
. -- DEDUCTION FROM ASSESSED VALUATION
� �� Smle Fam 43710 (R9 / 9-08)
��'� 'w � Presaibed by Me OeG��� d lool Gove�mnanl Firarcre
formatiom m�taineE in Ws doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). �� �
/N51RUC710NS:
G'J. n`-�
To be fited in person w by mail with the CountyAuditor o7the county where fhe property is bcated. v ��
Filing Dates: 1J Real Property: Dunrg fhe year /a which the deUuction is sought V
2) Ab6ile Homes assessed untler IC 6-1_ 1-7 or Manufactured Homes nd assessetl as Real �S .h�'n�4bbi�k��4T�,�ms ea�
March 31 0/ each year fhe indivi�ual wishes fo obtein the deduction.
Sea ieverse side far addifional insWUions and qualifirafions.
Narne d eGd�b (owrier or contrart
� Q �
�s aavumm tna sae �egai o� av�asda o.,,�an M Na. whal is � er esacl shara of "u�taresC! owned wiih someone alher Uun sVa+m.
indimte wifh whom
❑ Yes ❑ No � � �
M`ame m record is diCarenl ihan ihat d applkant iMinte bebr.
NarnedcanUad r
�'`
Address d d se0ar (num6er and struot. dly, stab. antl LP mde) Is �ha proparry in Que�++�.
PropertY ❑ MrniaBYAssessed
� bbdle Fiorne (IC 61.1-7)
Is appliom biintl u CefineA in IC 72-7-2-21(1r7 Is apqiram disa0led and unable lo erqage in arry w�slaNial gaiMul aUiviry
as defiried in IC 61.1.12-77(d)7
❑ Yes No es ❑ No
Is Ihe V��M usad and omiP�d OMmM' br ti r�astlence? Ooes Ihe apG��M�s Iande gr�s uxome br Ihe 0� m8 ralandar y°_•
exmeE t17.000? '
�Yes ❑ No ❑ Yes ❑ No
m�A Key number / Legal Eesaiption Remrd numbar Page number
-'� a �i a� 0�-30��. aa
IIWe certi(y under penally of perjury lhat lhe above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforemenlioned properry on March 1, 20
Si�natura d appGCam AEtl2ss ot applimnl (raunEef aM sboe(, tiry, sla�, aM Z/P mde)
< < � em -1�4 .� ' 70
Signalwe d auNOnzed represeniativa MEress of authorized representative (nun4randstreef, ciry, 5ate. an0 LPCOCb)