HomeMy WebLinkAboutDisabilty_Blume�� 4` APPLICATION FOR BLINO OR DISABLED PERSON'S c ow rEn.a
,.� DEDUCTION FROM ASSESSED VALUATION ..�
�l Sta1e Fwm 43710 (R7 ! 5-o6)
Aesai6ed b y Ihe D e p a r U n r s i d L o m l G o v e m m m� F i n a n c e
�'ntormation contained in ihfs documeni is CONFIDENTIAL pursuant to IC 72-1-7-1(n) and IC 6-1.1-12-12(b�. O C T L���h"Et'lv0
iNSTRUC710NS:
To 6e Iiled in pe�son or by mail with the County Auditor of (he county where Ihe p�operty is located. �p—y�,�, �
Filing Dates: f J Real Property: Dunng the 12 months 6efore June 17 of the year the deduction is to be effec �(be. � �
2) Mobile Homes assessed under IC 6-1.7 J: During the 12 monihs 6efore March 2 0! e62�$@2y (2@IhN7f�Ydb�1CWTSA@s to
obtain the deduction. �
See reverse side tor addrtional instructions and ualircaGons.
Name of licani (ownei o� contract buyeiJ
Q'
Is applicant the sole Iegai or equitaWe owner? If No, what is hislher exaG share of interest? If owned with someone other than s
pouse.
indicate with whom
❑ Yes ❑ No
If name on record is different than Ihat of applitanL indiwte below
Name of mnVad seller
Address of conVact seller Is the property in question:
❑ Real Property ❑ Mob�e Home (IC E1.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-7.1-12-12(b)? Is applicant disabled and unable to engage in any wbstantial gainful activiry
as definedinlC 6-7.1-12-11(d)?
❑ Yes ❑ No �,'S'es ❑ No
Is lhe property used and occupied primarily (or his/her residence? Does Ihe applicanPs taxa6le gross inwme for the preceding wlendar year
exceed $17,000?
Yes ❑ No ❑ Yes ❑ No
lawng district Key number I Legal descrip6on Record number Page number
��� ��L� 02� -/8 - /3 - Yo`f -DvO. /l! oa �
IIVJe certiry under penalty of perjury that the above and foregoing information is true and correcl and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
X S�9^�� �� aPW���i Signawre of authorized representative
//
✓ X liinxi
AdCress of appGcant Address of authorized representaWe
i D a �.s�' �rka �,� .�,-