Disabilty_Vanvliet. ... _ _ _ _ ;- _,..�-
°� APPLICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSHIP r�
- DEDUCTION FROM ASSESSED VALUATION
� .. State Fpm 47710 (R9/9-08)
.' ° " 1
Prastnbed by Ne Deparlmen� d Local Govarnmanl Finance �
�nformat"qn contained in this doaimenl is CONFIDENTIAL pursuanl to IC 6-1.1-12-12(b). � �� )
inrsrnucnoNS: � $EP 3 0 2009
To be filed in person w by mail Mith Ure CamtyAudifw ol fhe county wheie the property is bcaled. �
Filirg Dates: 1 J Reel Prt�perty: Dunng the year lar which the detlucfim is sought �
2) Mobile Homes assessetl unOer IC 6-1.1-7 or Manufectured Homes not assessed as Real Pmperty: Qu�� e Av��ej(� months 6e1ae
Mamh 31 0! each yea� tl+e lntlivitlual wishes to abfain the deductian. ��
See�eversestlelcradditionalinsLudionsandqualifications. Rc OUNTY AUD11Un
NamedzvP�b(a��' �d � ' I� •
U
Is app6mrq Itre sde legal w aW��� �T��! H No, whal is his�har eua share d interesYt C owned wilh someone aher Nan spouse,
iMita�e wilh Mrom:
❑ Yes ❑ No
tl �ama m remrd "a CiQ9ren1 Ihan tlu1 W app6ant, i�ivte babw:
Nama d conhad se0ar
�
Mdrass d mnbatl sa0er (num a strcc4 �+�Y. sra[c. and ZIP oode) Is 1he - 9uestian:
�Raunv p a,�,auvn�se�a
Mo6ae Flort,e (IC Gt.t-7)
�s acv��m ne�d as eas„ed m ic �2-�-2st{i p Ls apqicant disabled aM unable lo e�gage'v� arry substaN'vl gaiNul atlivey
as a�ree � ic �i.i-iz-i��e�a
❑ Yes o es ❑ No
Is Na propeM u� antl oecuped pnmany fw �is/her restlefxa? Oces Ihe aPP�iwnfs IazaWa gr�s imm�a for lhe preceding calentlar year
� exmed 517.000?
es ❑ No ❑ Yes ❑ No
Taaing Key numoer / legal Eesaiption Remrd number Page number
`�rL�r�c.c�� a�- �� /�-3%�3. 019
IIWe certify under penalty of perjury that lhe above and foregoing information is We and correct and thal lhe appiicanl was a resident
of Indiana and owner of ihe aforemeNioned pioperty on March 1, 20
SignaturadappliraM Adtlressolapptiam (nunDera�n/tlstre et,rily.sla� andZlPmde
�O.J CT J)C/!S/�[� �Oi(_, /�.
/ .--�—' 'S�
' nature d a 'zetl tepresenlative Atldress of aulMnzed represaniative inumf�aM 5LOe1, [ufy, sfato, a�M LPCOOe)