Disabilty_Thornton�
a•
'°"' � APPLICATION FOR BLIND OR DISABLED PERSON'S SHIP venR
� -- : DEDUCTION FROM ASSESSED VALUATION
S �= su�eFom�aa�ia�RSia-oo) .
Preuribed by ihe Department of Local Govemment Finance
In�-^+ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-1.�-72-12(b). APR 1 5���lark
�,�ucr�oros:
To be filed in person or by mail with the County Auditor of the county where the propeRy is located. ��
Filing Dates: i) Rea/ PropeRy: During the 12 months befo�e May 11 0( the year the deduction is to b€ e��ve �`�`
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before MarcFRB$�9�8§dCUltheyQJ(qyj�y�l wishes to
obtain the deduction. �
See reverse side for add'rfional instnrctions and ualificalions.
Name of, pliwnt (owner or contract buyer)
�, }-�- , � lto�, �
Is applican� e sole legal or equitable owner? If No, what is hislher exact share of interest? If ovmed with someone other than spouse,
indicate vnth whom
es ❑ No
If name on record is difterent than that of applicant, indicate below
Name of conVact seller
Address of coniract seller Is the property in questlon:
❑ Real Property ❑ MobBe Home (IC E1.1-7)
Is appiicant blind as defined in IC 12-7-1-7(n) and IC 61.1-12-72(b)? Is applicant disabled and unable to engage in any substantlal gainful activity
as defined in IC &1.1-12-�1(d)?
❑ Yes ❑ No L7 res � No
Is the property used and ocwpied primarily tor his/her residence? Does the applicant's Wuable gross income for the preceding calendar year
exceed 577,000?
❑ Yes ❑ No ❑ Yes ,� No
Ta�dng district Key number / Lega� descriplion Record number Page number
� c1�-�a��9- c�
��
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signat of applicant Signature of authorized represenWWe
,� . a�.�-�
Addres of app cant Address of authorized representative
� S � P-�