Disabilty_Shawgo-� ..
APPLICATION FOR BLIND OR DISABLED PERSON'S couKrr rownsn�P r�
- - DEDUCTION FROM ASSESSED VALUATION
�- - 51a1e Fpm 43710 (R9 / 908)
�s i
�"" Prescnbed Oy Ne Oepartrtrenl d Lool Govemnenl Finance
orma6rn mntainetl in tttis doaimenl is CONFIDENTWL pursuaN ta IC 61.7-12-12(b). FI M y�
INSTRUCTIONS: �"� �l.,./ j�
To be Red in person or by mai/ wi(h the CaintyAuditw o/ Ne oounry wheia tlre poperty is bcated.
Filirg Dafes: f J Real Pmperty: Dunrg Ne year (or wh,ch the tletluctia� is soughf. �AY 2 f �-� ,
2) Mobile Homes assesse0 uMer IC 6-1.1-7 or Manufactured Homes nd assessed as Real Propeify: Dunlg the AveNe (12) monfhs`befae
March 31 0/ each year Ihe individual wishes to o6tain the deducfion. ���
See reverse stle lor additional insWcfions antl 4�lificaGOns. "�� �f
name m avv� (�a. �awaa wqer) ON COUNTY n:: ��-_ :
% i� o�`lA-(� �' o
Is applicanl lha sde legal or eQwtade owna/? H No, what is hisrt�er ezad shara o( i�narasl? M owned with sorteme olher Uun spouse.
indim�a wilh Wpm:
❑ Yes ❑ Na
tl name m record'u EiOerenl tlun mat d app4ranl ��'�e bebw.
Name of cmiraU SeOer
Address N mnvaa mGer (menb� an0 sbnc�. tiry. sfa�. aid ZIP mtlo) Is popery in Queyun:
rx�Pr�v 0 a��.,�ra�a
Mohae Horne (IC s1.1-7)
Ls appbram WinE as defined in IC 12-7-2-21(11? Is appicant dLsabled ard unabla b ergage in arry wbsfanlial gain(ul adiviry
as tlefined in IC &1.1-1247 (d)?
❑ Yes ❑ No ❑ Yes ❑ No
Ls Lha G�aM uso0 aM accu0�d O�aY br �aArer resderca? Doas Ihe e7d�nfs luable gross irrnine (w Ihe O�etUdinB talenCar year
exmed 517.000? '
❑ Yes ❑ No ❑ Yes ❑ No
Tazmq Ois�nd Key number I Legal Gexrlption Recwtl number Page numEer
l:Yw-�� �o-/ - d� .3o3Aav.3(9 Q 6
INVe certify under penalty of pe�ury lhat fhe 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 _
Signature ot applicam J Aedress af appWant (imribol aM street, tlry, stam, a�M ZIP mtle)
���� l� 2 os s, w.•//, Js, ,�� r�...,�� /ti �/7G Y�
SignaWre d authonzed representative Mdrass of authw¢ed raprasentalrve (numDeiaM sVOe( city, sfata, arW LP co0e)