Disabilty_Martin (3)•°'" APPLICATION FOR BLIND OR DISABLED PERSON'S courrrr TOWNSHIP rea.n
. DEDUCTION FROM ASSESSED VALUATION � �
State Farm aJ710 (R9 / 9-OS)
�+ I
PrBStribed by Iha DBp3rtmBM d lofal Grnernmanl Fnance
Information oontained in tlds document is CONFIDENTIAL pursuant W IC 6-1.1-12-12(b). DEC O ZU I� Mafk
INSTRUCTIONS:
To be filed in person w by mail wi(h the CountyAuOrtor o( fhe camty where the property is bcated. C.�.
Filirg Dafes: 1) Real PropeRy: Dunrg the year for which the deduction is sought.
2) Abbile Hpnes assessed under IC 67.1 J w Manu/actured Homes nW assessed as Real �2J months be/ae
March 3/ o/earh yee� tlie indivMual wishes fo obtain the deductian. GI BS�O���
See reverse side /ar additional insWdions arnl aualifications.
I5 appfimN tha sda legal w
H No, what is t�islher exaG shara d interestl
es ❑ No
tl nanie m recard'a d�arPnl lhan tlut tl appbtant i`Wnata bBbw:
AOdrass of mrtrad se0er (mim6ci and sbeel, cify. 5fate. and ZIP oDde)
Is appticaN bGna az debned in IC 12-7-2-21(1 �?
ma �rty
Taz' 'sinU ^
� ♦ �
Yes U No
ar�v For �ismer re
❑ Yes ❑ No
Key wmber I Legal Cestripl'an
tl owneE w0h mmaone
'vMitate wRh wlqnc
Is Ne vweM in wesfim
❑ R� a�Y ❑
Ls avq�m aaan�ea ana unaae m engage in ary
as defined in IC G7.1-12-17(d)?
Doas Ihe appfcaM's tavble gmss incmie br Ne
es�ee St7.000? �
-'17v/ i{�1/ll �
spouse,
acSivdy
No
❑ Yes ❑ No
Recortl number Paqa number
��c ��.i-i�
I/We certify under penalty of perjury lhat lhe above and foregoing infortnation is We and correct and that the applicanl was a resident
of Indiana and owner of lhe aforementioned propeRy on MarCh 1, 20
representalive
7
Adtlressofapp6�nt (mmDeiandsbeel.afy,state.aMZlPwde)
(numDer aid shcel. city. 4atc. and LP code)
�D/N �/iLGM=� S%
s+�
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