HomeMy WebLinkAboutDisabilty_Kiesel� 4� APPLICATION FOR BLIND OR DISABLED PERSON'S couNrv TOWNSHIP r�aa
DEDUCTION FROM ASSESSED VALUATION
State Form 437t0 (R7/5-06)
: �Y
PresaiMd by the DepaMrent ol Loral Govemment Fina�xe
��nfortnation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-7.7-12-12(� ��/ �e 3 a �
:VSTRUCTIONS: ta--{
To 6e rled in person or by mail with the County Auditor of the county where fhe property is !o �f. lLJ
Filing Dafes: 1) Real PropeRy: During the 12 months before June 17 0! the year the deduction is to b ffec�(iv .��f1f1
2) Mo6ile Homes assessed under IC 6-1_7-7: During the 72 months beto�e March 2 of���i y6a�IXeVq�"vidual wishes to
obtain the deduction.
See reverse side for additional instn�r.tinn.c and nualifi�a6r,o< `—�.. �, .i
of applrca�t (owner
appiiwnt the sole legal or equitable ovmer?
❑ Yes ❑ No
name on rewrd is diHerent Ihan that of appliwnt,
ame of conVact seAer
ddress of conVact seller
appliwnt blind as defined in IC 72-1-1-1(n) and U
P�oPertY
O Yes ❑ No
❑ Yes ❑ No
residence?
�,
avmed with someone
tlicate vrith whom
Is the property in question:
spouse,
�❑ Real Property O AAob�le Flome (IC G7.
applicant disabled and unable to engage in any subsWnUal gainful activi
defined in IC 6-1.7-12-17(d)? ,
taxable gross income
❑ Yes ❑ No
r the preceding calendar year
❑ Yes ❑ No
nting dLStnct Key number I Legal descrip6on Rewrd number Page num6er
�- ��✓1ct�,�G� a�- ��- ���o y 000_ s-aa.�
I/We certi(y under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ .
r
appGwnt
`P� ��u rn c � �, �, ;
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Address of authorized
representative