Disabilty_McKimmy/
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�-� APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr TOWNSHIP r�na
s. DEDUCTION FROM ASSESSED VALUATION
State Fortn 43770 (R7 / 5-OG) � �
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�"° Presa�e.d by the Depariment W lod Gwertimrst Firvvic¢
I�n(ormation contained in this documeN is CONfIDENT�AL pursuam to iC 12-1-1-1(n) and IC 6-7.1-1242(b). � h
INSTRUCTIONS: ,IU�f 2 3 2009
To be /iled in person or by mail with the County Auditor o/ the county where the property is locafed.
Filing Dates: 1 J Real PropeRy: During the 12 months 6efore June 17 of the year the deduction is to be cnve.
2J Mobile Homes assessed unde� IC 6-1.7-7: During the 12 months befo�e March 2 0/ ac �c'� ividual wishes lo
See reverse side (or addit o a�nstrucfions and ualificalions. ��BSON COUNT y��*0�
Name of aDnlicant lowner or contrac( bwed 9
�
�
or equiWbre ovmer? � I I( No, what is his/her� sii�are of interest? If owned with someone other than spouse,
/ / indicate with whom
❑ No
name on recora is tlmerent V(an tnat ot applicant, indicate below
ot wnVad seAer
conirad seller
Is the property in question:
Real Property ❑ Mob�le Home (IC G7.1-7)
appiicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-72-12(b)? Is appliwnt disabled and unable to engage in any substantiai gainful acliviry
. as defined in IC 6-1.1-12-N(d)?
O Yes ❑ No ❑ Yes No
the property used and ocwpied primarily for hislher residence? Does the appliwnPs laxable gross income for the pre ding ralendar year
exceed $17,000? ,
Yes ❑ No Yes No
uting district Key number / Legal description Rewrd number Page number
� �, ,�. . a/_�9 ��-io�- oo� iG� oa6 .
I/We certify under penalty of perjury that the above and foregoing information is Irue and correct and that the applicant was a resident
of Indiana and owner of the atorementioned property on March 1, 20 �
� ISignature o( appliwni SignaNre of authorized
.:� 'i Yli YI, %/ `
� hoaress o� appucan[ . // Address o(
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