HomeMy WebLinkAboutDisabilty_TerryS����� APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R7I5�06) .
Presm6etl by 1he Deparvnrnt af Lo�l Gwemment Fina�r:e
COUNN TOWNSHIP YEAR
�
�Information contained in this document is CONFIDENTIAL pursuant m IC tt-1-1-7(n) and IC 6-1.7-72-12(b). � Fi ai '
NSTRUCTIONS:
To be �led in person or by mail wifh Ihe County Auditor o( lhe county where fhe property is locafed. � E � 1 6 2��$
Filing Dafes: 1 J Real P�operty: Dunng the 72 months before June 77 of fhe year the deduction is to be eNective.
2J Mobile Homes assessed unde� IC 6-7. 1-7: During the 12 months 6efore March 2 ot each year the individual wishes to
obtain the deducfion. �%/ � ,G` �
See reverse side for additional instrucfions and ualifications. � �.iTV ni i R
� Name of applicani f�vmerorcontracf buyer) A •– �
I1 .
�s apwiwnt uie w1=legai or equtia6le owner?
V V
❑Yes ❑No
If name on record is diflerent Ihan Ihat of applicart
Name of contracl se4er
Address of conVact seller �
Is appliwnt blind as defined in IC 12-1-1-7(n) and
ProPertY
disVict
❑ Yes ❑ No
and occupied primarily tor hislher
❑ Yes ❑ No
No, what is
If owned vriN someone other than spouse,
indicate with whom
Is the properry in quesGOn:
❑ Real Prope+lY ❑ Moble Home (IC 61.1-7)
1.7-72-72(b)? Is applicant disabled and unabie to engage in any substantial gainful activiry
as definedinlC 6-1.1-12-17(d)? ,
� Yes ❑ No
�esidence? Does ihe applicant's taxable gross inwme for ihe preceding calendar year
exceetl $17,000?
❑ Yes ❑ No
:y number 1 Legal tlescriptlon Record number Paae numher
I/We certify under penalty of perjury that ihe above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on Marcn 1, 20 _
�'�
of authorized
representative
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