HomeMy WebLinkAboutDisabilty_Speedy°'" t APPLICATION FOR BUND OR DISABLED PERSON'S couNTr TOWNSHIP vea,R
; DEDUCTION FROM ASSESSED VALUATION
-� � ; State Fortn 43710 (R6l 4-04) �
Prescri6e0 by Ihe Department of Local Govemment Finance
�ahon wntained in this document is CONFIDENTIAL pursuant to IC �2-1-1-7(n) and IC 6-1.1-72-12(b). File Mark
ucnoros: JUL 2 6 Z006
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1J Real Property: Dunng the 12 months before May 11 0( the year the deduction is to 6e effective. ,�!�
2) Mobile Homes assessed under IC 6-1.1-7: Dunng the 12 monfhs 6efore March 2 of each�ar�e �ndividual wishes to
obtain the deduction. ,. ._ r,iasnu rn:��.r� . �..,..�
See 2verse side f r ad�
IName of applicant e
Is applirant the sole le
If name on rewrd is differ
Name of contract seller
Address of contract seller
or contract buyerJ
or
❑ No
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.
exaci
interest?
����.��
1 wiih someone other than spouse,
with whom
Is lhe property in quesfion:
�"RFaI PropeAy ❑ Mobile Hwne (IC 61.1-
Is applicant disabled and unable to engage in any subsWntial gainful activily
as definedinlC 6-1.1-12-11(d)?
❑ Yes C�Y o ❑ Yes ❑ No
� roperty used and occupied primarily for his/her residence? Does Ne appliwnt's taxable gross inwme (or the preceding calendar year
exceed 517,000?
5 ❑No �-�a /c� /�' /03 —00/, y9�3-oa-8 ❑Yes o
ocing disVict Key number / Legal description Record number Page number
P -- ���-��� 3- �
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
gnature of applicant n � Signature of authorized representative
N •
of authorized representative
�= /o0 7 .S. /�.9i/ 5T, YiP.��
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