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� APPLICATION FOR BLIND OR DISABLED PERSON'S c r�
. - . DEDUCTION FROM ASSESSED VAlUAT10N
� Sfata Fmn 43710 (R9 7408)
� '� J Raw3eE Ne De
by pazimem d Lolal Grnemmianl Fnance
�nformafiom m�tainetl in Nis document is CONFIDENTIAL pursuant to IC G7.7-12-12(b). DECFi� a
INSTRUCTIONS: t�-�y
To be filed in persm or by mail with the CountyAuditor o7the wunry where Me poperly is located. C� n\�J I. \_\
Fdirg Dates: 7) Real Property: Owing the year Iol whch the tleduction is sought �� v
2) Mo6ile Hwnes assessed uMer IC 6-1.1-7 w Manufadured Hwmes rrot assessea as Real Propert�dJargg fpg��((f4�liqon�i�be/ora
Maich 37 d each year Me individual wishes fo obtain the deduction.
See reverse sitle Im add"dional inshuctions entl aualifications
Name of aod� (awrar or fmtract buye�
� '
Is appfimM Ihe sda lega� or epuiUWe owna . H No, w1u1 o hivher asad Share d irrteresl9 tl owned wilh wmeane ahar Nan sVase,
itWicate wM1h whom
❑ Yes ❑ No
tl(unie m �amd is C�ereN tlun Mat d appfranl ��cate Debw.
Name W contrad se0ar
Pddress d mnVaa wEer (numDer antl sbeel �Y. sbb. and LP mtlo
) Is m proparry in qua��.
�R�Pr�v O a,�,aor��a
rnobae r�,� ��c si.�a�
Is applxaM bGnd as tlefined'm IC 12-7.2-21(1 �? Is appiiram disabletl and unaMe lo e�gaga in arry suhstaNiat gairiNl atliviry
� a�r�d � ic �-i.i-�z-ii�dp
❑ Yes ❑ No � ❑ Yes ❑ No
Is Ne propaM used and occupied primarily br his/her rasdenca? Doe- Ihe applifanfs lande grnss inm�ne br U�a precedug talan0ar year
exwed 517.0001 '
p� Yes ❑ No ❑ Yes ❑ No
�distrid Keymimber/Legaldesmiption Remtlnumber Pagenumbor
iu,,,.��„� a6-��-rs-aoi- �oo.Ya� x�
IIWe certify under penalty of perjury Ihal the above and foregoing information fs true and correct and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20
Signatura d appGraN ACtlress ol apptioM (iumberantl streol. cdy. staR. antl ZlPwtle)
k.k%-�-� k l�% l�.?Y S P�RIN� ST �����ce%ri .�N y7� %0
Signalure of a�Maizetl represantalive P4Aress ot auttarized reprasenta�ive (numbwand shcn4 cify, sfafe, anOLPCOdc)