Disabilty_LearAPPLICATtON FOR BIIND OR DISABLED PERSON'S
-- DEDUCTION FROM ASSESSED VALUATION
Stale Wm� A3710 (R9 / 9-OB)
S'�+ �' Prrrn'Led by the �epartrrenl of Loml Gove+ru�nl Fnance
COUNTY T0INNSHIP YEAR
� A �
�nfimiation contained in ihis doameM is CONFIDENTINL pursuant to IC E1.1-12-12@). � �� �e �
, . �RUCTIONS:
fi/ed in person or 6y mad with N�e CountyAuddw otthe oounty where Ne property is located. A P R 9 2�i712
'� rwng Dates: 1J Real PiopeRy. Dunrg the year hu wh� the deduction is swght. \,_
2) MobJe Hanes assessed underlC frf.1-7 w Manufactured Homes rrof assessed as Real PiopeRy. Durr7tg�dreTivetve (12J monfhs before
AQarsli 31 of each year the irrd'rvidua! wrsties to obtarn fhe deduction. �� ��
See /everse side for additional instnrc8ons end qualihcations.
!� Name of aDd�t (ovmeror contracf buynd
' �f ctn k P d. �onn� IYl l.�a�'
I �s �t me sde � a ea� o�en if Na wna� i� � exaa snare or �n�?
�Yes ❑No �
n freme on recora +s amerem Na�, a�at or apcuran� mekate eerow
� �
tonVaU seller (numbera
Is appCqant Efcd as deTmeC in IC
h fhe MoP�nY uxd md ocwpied
u�ec an, srare,
Yes
❑Yes ❑No
F+ L��an cP�
KeY num0er / �epal desr�tion
n ovmea xitn someone otlrer u�an spouse.
udirate with W�om:
a�cem m a��2
��Y � �Y�
tv� F{ome (IC 6-t:
@ap�n i dsa6lea aM unaDie to engage N enY ��� 9� �+'¢Y
as defureC in IC 61 A4241(Ci!
ta�we g�as incortre tor tlre
01 �- I 9- I 9-I ol -oo o. �/u
Remd num6ef
❑ No
cebndar year
❑ No
Pape number
UWe certify under penalty ot perjury that the above and foregoing infortnation is We and correct and that the appiicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Address of aPPGram (runn0erand sLee4 �Y s�ate, antl LP oode)
� %, �� l� (o °� �- !�%�:(.Ls.�cPi ��. ���.�L, .�N /�71��f8
represernative AGCress�auttwrizeCreWesenm6ve (n�m�6erendabeet,cdY.smte.arMLPcode)