Disabilty_Cockerham°"' APPLICATION FOR BLIND OR DISABLED PERSON'S
. - . DEDUCTION FROM ASSESSED VALUATION
S � sem F«m aa»o �as i sm�
Presaibetl by Ihe DepartmaN d Loml Govemmerit Fnance
.� � tbm m�taned in this Ooamen� is CONFIDENTIAL pursuant to IC &1.1-12-12(b).
TOWNSHIP YEAR
J
MAY 1 Ftle2��l
INSTRUCTIONS:
To be filed in person or 6y mail with the Co�nfyAuditor o/ fhe camty wfiere the property is bcated. �7�
FTirg Dates: i) Real PropeRy: Dunrg the year /or whic/r fhe dedudion is sought. �' "� rQ
z) Alobile Hortres assessed uMerlC 6-1.1-7 or Manu/actured Homes nd assessetl as Real��D��N7Y� �TOR � be�
Mamh 37 W each year tlie individual wishes to obfain (he deduction. Od
See reverse side !or atlddional insWUions arM qualificafions.
Nama d evv��b (owrar u cantiact buye0
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�s ecvtimm me sda iegai o� eyuaabie ow�en H No. whal o h'srher asad share d'vae�est7 t( owned wifh sorreane aher Nan sowsa.
indim�a wilh whwrt
Yes ❑ No
tl�me m racartl is d'Aarem ihan t d appGfanl intlirrta beb.�
Narre of mnlraG 5e0er
Address d m�trad se0er (nurti0orand sboo( UY• mb. aM LP co0a) Ls �he W WaM in O�slim:
Rea�Praperlr ❑ nnrx,aeywssessea
AAoh�e Fiorne (IC G7.1-7)
Ls applimeq btind as tlefineE in IC 12-7-2-2711 jt Is applimnl disableE anC unade to engage in arry suhstantial gaiNul aflihty
as defineC in IC 61.1-12-11(d)?
❑ Yes No u Yes ❑ No
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BzCBEd Si�.��% �
� ❑ Yes ❑ No ❑ Yes ❑ No
Tarvg Gistrid Key number / Legal desuiplion Remttl number Paga number
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I/We certify under penally of perjury Ihat lhe above and foregoing in(ormation is true and cortecl and that Ihe applicant was a resident
of Indiana and owner of !he aforementioned propeAy on March 7, 20
Signatura dappGraM Pdd2ss of appliranl (.mnberaiM street, aty, sfa�, aiM ZlPCOtle)
� ' � sE
� nal�re d auNaized reP�ntative Pdaress ol auUar¢etl represanta�ive (nwnDer and sheet. MY, �aro. and LP code)
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