HomeMy WebLinkAboutDisabilty_Spurgeon'°'° APPLICATION FOR BLIND OR DISABLED PERSON'S couNTr TOWNSHIP vEn,a
�- � DEDUCTION FROM ASSESSED VALUATION
S ; State Fortn 43710 (R6 / 4-04) .
Preuribed by the Department ot Local Govemment Finance
Ir,� tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-�2-12(b). F�le ark
ul�rucnoros: � � �
To be filed in person or 6y mail wiih the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 0( the year the deduction is to be e(/ecf/v,e.
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months before March 2 of each ye�aE�h�%indi�7� wishes to
obtain the deducfioa -
See reverse side for additional instructions and ualifica6ons. �"lj . „,,
Nameofa�cant(ownerorcontractbuyer) � ��tl9pNC0 NTy•+6y�TOq
� AUD
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Is applicant the sole lega or equitable own R If what is hisRier exact share of interest? If owned with someone other than spouse,
� indiwte with wham
❑ Yes ❑ No
If name on record is different than that of applicant, indicate below
Name of conVact seller
Address of wntracl seller Is the property in questlon:
Property ❑ Mobile Home (IC 61.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)? Is applicant disabled and una e to engage in any substanlial gainful acfiviry
as defined in IC 6-'1.1-12-11 �
❑ Yes �110 ❑ Yes
Is ihe property used and ocwpied primarily for his/her residence? Does the appliwnt's taxable gross inwme for the pre ing calendar year (
� exceetl 577,000?
❑ Yes L�o ❑ Yes
T� g disVict Key number / Legal description Rewrd number ge number
a�- �a-�� - ao� -�a.,a�-��
I/We certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representative
ress o applicant ` Address of auihorized representative
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