HomeMy WebLinkAboutDisabilty_Zeigler_`^ `:"4 APPLICATION FOR BLIND OR DISABLED PERSON'S CouNn S YEart
� s�'.y.[n i DEDUCTION FROM ASSESSED VALUATION
',�i � Siate Fmn E3710 (R7 / SOG)
Aewibe.d 6y Ihe Departrnan W Laal Govemment Finance
�Infamation contained in this documeN is CONFIDENTIAL pursuant to IC 12-1-1-7(n� and IC 6-1.7-12-12(b). MAY �����
NSTRUCTIONS:
To be tiled in pe�son or by mail with the County Auditor ot the county where the property is locafed. � �
Filing Dafes: 1 J Real Property: Dunng the 12 months betore June i l of the year fhe deduction is to 6e etfe�tiJe� R
2J Mobile Homes assessed under IC 6-1. 7-7: During the 12 months before Ma�ch 2 of���m�W�(vR1ii��Shes lo
o6fain the deducfion.
reverse sfde for adddfonal Instructron
ie o( applitant (owner or conVac[ buye�)
�
�plicant the sole legal or equitaWe owner?
If name on record is difier
Name of contracl seller
Address of conVact seller
Is appliwnt blind as defini
Is ihe property used and c
�axing i ct
1 . �
O Yes ❑ No �
an that of applicant, indicate below
in IC 12-1-1-7(n) and IC 6-1.1-12-12(t
❑ Yes J�No
upied primarily for his/her re5idence?
�Yes ❑ No
Key number I
TY`� �Ii_ _ /1
exaU share of interesi?
applicant disaWed and ur
� defined in IC 6-1.1-72-11
-07- /o/-��/yd7
owned vrith someone other than spouse,
dicate with whom
Is Ihe property in
�Real Property ❑ Mob�e Home (IC 6-t.
ible lo engage in any subsiantial gaintul activi
d)?
�,Yes ❑ No
gmss income (or Ne preceding calendar year
Rewrd
.�
❑ Yes ❑ No
INJe certiry under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
o( Indiana and owner of the aforementioned property on March t, 20
c�naNre ot appficant n SignaWre o1 authorized representative
authorized
0