Disabilty_Smith (4), ���� APPLICATION FOR BLIND OR DISABLED PERSON'S c � o rea.R
DEDUCTION FROM ASSESSED VALUATION �
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` f State Fmn a3710 (R7 / 506) _`�
Prewibtd by Ure Depvtr�nt d Loral Govemm¢nl Finance ��
��fwmation contained in this dxument is CONFIDENTIAI pursuant to IC 724-7-7(n) and IC 6-1.1-12-12(b�. UN �eij�1�Q�
NSTRUCTIONS:
To be (led in person or by mail with the County Auditor ol the county where the property is focated. •�
J'/a� .� �
Filing Dates: 7) Real PropeRy: Dunng the 12 months before June 7 7 oJ fhe yea� the deduction is to be ef/ecUVe.
2) Mo6ile Homes assessed under IC 6-1. 1 J: Dunng (6e 12 monfhs be%re March 2 0( eacl3�9�'r th��iiftlN�d6aJ�rys fo
obtain the deduction.
See reverse srde (or additional insWr.tinn.c and m�a1���ar��„o
3me of appliwn ner or confract
applicant e ole legal or itable
V ❑ Yes ❑ No
name on remrd is diHerent Ihan Ihat ot appiiwnt,
ame of contrad se r
idress of contra Iler �
applicant blind as defined in IC 12-1-1-1(n) and U
Is the property
�
�
7
❑ Yes �No
ied primarily (or his/her residence?
ffiYes ❑ No
his/her exact share
applicanl c
� defined in
I with 5omeone
with whom
Is the property in queslion:
spouse,
�� Real Property ❑ Mpble Home pC 6-1.1-7)
�d and unable to engage in any subs�antial gainful acliviry
1.1-12-11(d)?
�/ / �
taxable gross income
❑ Yes O No
r the preceding ralendar year
O Yes ❑ No
Page number
IMIe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20 �
�
X I J'%�_-� /I� ��t//...on.,.n
Address of authorized
represenUtive