HomeMy WebLinkAboutDisabilty_Stone°"' . APPLICATION FOR BLIND OR DISABLED PERSON'S
; DEDUCTION FROM ASSESSED VALUATION
, _ � �atate Fortn 43710 (R6 / 4-04)
Presuibed by ihe DepaNnent of Local Govemment Finance
COUNTY TOWNSHIP YEAR
I ation contained in this document is CONFIDENTIAI pursuant to IC 12-1-1-1(n) and IC 6-7.1-12-12(b). File �
i�iucrioros:
To be filed in person or by mail with the CountyAuditor of the county where the property is /ocated. �P R 2 � Z��S
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 of the year the deduction is to be eHeci'
2) Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months belore March 2 of each yea� the individual wishes to
obtain the deduction. - a� H
See reverse side for adddional instructions and ualifrcafions. (/ ��} f�
Name of applicant (owner or conVact buyer) /J , l� :TOn i
applicant the
D No
on
contrect seller
is hislher exact share
indipte below
Address of wnirad seller
�(0-�9-►`�-ao3-oo�
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)?
is Ne pmperty
�
Is
as
❑ Yes No
ed primarily for hislher residence? Does
excei
es ❑ No
Key number / Legal description
1 with someone other than spouse.
vrith whom /
.�'/N/�4 - _/uil.�
Is the property in question:
'� O� �1 Real Property ❑ Mob�e Home QC 6-1.1-
znt disable and unable to engage in any substantial gainful acfiviry
ed in IC 6-'1.1-12-17(d)? ,
�Yes ❑ No
gross income for the preceding calendar year
❑ Yes
I/We ceAify under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
�nature of applipnt �
-�-��`vYV~J /// , ���
dress of applicant
�/ ,e � a �a Q� ,(i
of authorized representative
ofauthorized represeniative