HomeMy WebLinkAboutDisabilty_Smith°"' APPLICATION FOR BLIND OR DISABLED PERSON'S courm TOWNSHIP renR
- . DEDUCTION FROM ASSESSED VALUATION � � �
•S � - ! Sfaro fortn 43770 (R919-08) i
� Rasaibed Cy Ne Department of lo�al Gmenvrienl Financo
�
�iforma[iam m�tainetl in this dowment is CONFIDENTIAL pursuant ro IC 6-7.1-12-12(b). Fle Ma
wsrnucnoNS: APR 6 'LUII�`
� To be filed in person w by mail �aith the CountyAudr(or o7 the counry where fhe poperly is bcated.
Filirg Dates: i) Real PiupeRy: Dunrg the year Iw whech the deducfion is sough(. `%�J ,�
2J Mo6ile Hanes assessed under IC G7. 7-7 w Manu7actured Homes nd assessed as Real Properl}�.' b�the (72) monUrs before
March 37 deach yearMe irWiviDual wishes fo obfain the deduction. r•inc[11d COUNTV AUD�T9P
See reverse side (ar adddanal insLUdions and 9�lficafions "-- - '
Name of aGO� (amcr m cantrau dryeQ
�/�%��
Is aVP�N the stle iegaf m u de owrieR tl No. r1u1 is hivher exxf shara cQ irqerest7 C amed wiU wmea�e Aher Nan sVam.
'adiote with wtrom
es ❑ No
H�nie m record is diHereN than 10( appihant, iMifate babr.
Narne d mrtlrad se0er
Address d wnlrad se0ar (rvrn6n and sboel �Y. stab. an0 Z!P m0a) Is Na ptopetly in quastian:
RopertY ❑ AnrniaAyAssessed
Mo6de Flome (IC fr1.1-�
Is applionl bGnE as defined in IC 12-7-2-21(7 )9 Is applianl daabled anA unade to e�gaga in arry substarMial gaiMul aCiviry
as defined in IC 61.14241(d)?
❑ Yes ❑ No Yes ❑ No
Is na o�waM �e0 and om�piad pinwr�Y fw �oRwr ias0enee? Does 1he aPVdwnfs waOle gmss iricoma fw Ihe eceEing nleMar year
,�I exmeE 517.0001 .
I�Yes ❑ No es ❑ No
�Tazing E/'� q')a KeY number I Lagal Eesaiolion Recatl number Page number
U V ' _
IIWe certify under penalty of peryury lhat lhe above and foregoing information is true and correct and 1ha[ the applicant was a resident
of Indiana and owner of the aforementioned property on March 7. 20
Sign ura W m � Address ot applimnl (rwmber aiM sbeeL ciry, sfate, arM ZIP
2,� 9 w�s-� wa�.n�u % s7-. QiN c�-oN �`f767�
Signaiure d auUwriz repmsenWtive Addrass of aulhorized representative (numDeraM sfiee(. cily. 9afe, andLPwde)