Disabilty_Smith (5)APPLICATION FOR BLIND OR DISABLED PERSON'S couNn r iP v�
DEDUCTION FROM ASSESSED VALUATION
•; -'��1 SlabFartn0.377o(R9l9-OB)
P�esaibed by Ihe DepaNnerii d Loral Governr�i� Finance
�formatiom m�iained in this tlooiment is CONFIDENTIAL pursuant to IC 6-1.id2-12(D). N O V ��P� �9
INSTRUCAONS:
� To be filed in person o� by mail with the CainfyAudifw ol the �unty where the property is located. �-�„ �
Fllirg Dates: // Real Property: Dunrg the year lor wh "ch the deduclia� �,s sought Q���j �y
2) MobileHortresassessetluntlerlC&7.1-7orManufacturetlHOmeslwfaswssedasRealPropIB50N�(:UUNT ��sbefure
March 31 of each year lhe iiMrvidual wishes to obtein the ded�.clim. G
See reverse side /or adddional instnutions arM pualifications.
Name d aPWicaM (oq.�r ar cmhact 6uY�d
Ihe sde legal or equilade vwneR
❑ Yes ❑ No
If No, wFul is his/her ezatl share d iMeresl? H wmed wilh somea�e ottrer than spouse.
u�dimte wilh whorrt
H riame m(acad'a diRarent ihan Na1 of appfrant, iMicate bebw:
Name d mMrad se0er
AEdrass H oontrad seller (number antl sbeeL �: sbte, aM
Is appficaM b6rd az defined in IC 12-7-2-27(1)?
❑ Yes ❑ No
Ls Me popery us¢E aM arupieC primarily tor hislhar re
❑ Yes ❑ No
dislnd
Key namber / Legal Oesafplion
la-+B-�DI'
Is Uie G�WaM in m+a5ian
❑ R� R�v ❑
Ls apqimM disabled arN unada m engaga in
as defiered in IC 61.1-12-N(d)?
ezt»cd 41
Recortl number
n��n��d
hlohde Flane (IC 67.
/I gaiNul adiviry
1��
PrecWi^9 �IeMar year
❑ Yes No
Page number
UWe certify urMer penalty o( perjury thal the above and foregoing informa[ion is true and covect and Ihat the applicant was a residen[
of Indiana and owner of the aforementioned property on March 1, 20
$igna�ure o( applimnl
Address ol appliranl (iwmDer aM sf�ee( cify, sta�e, antl ZIP code)
P.dEress ol aultrorized reoresemative (number aM sbeef. cdy, sfate, and LP code)