Disabilty_Dewig (3)�"�� APPLICATION FOR BLiND OR DISABLED PERSON'S
�� DEDUCTION FROM ASSESSED VALUATION
3`
Stale Fmn a37 f 0(R7 / 5-OG)
�.�� Presaibed by Ihe Dep3riment W Loml Govemment Finance
COUNTY TOWNSHIP YEAR
�niormation contained in this document is CONFIDENTIAL pursuant to IC 12-7-7-1(n) and IC 6-7.7-12-12(b). F�
INSTRUCTIONS:
To be tiled in person or 6y mai/ with the County Auditor oI (he county where fhe property is located. �f OV Q s Z�Q$
Filing Oafes: 7) Real Property: During fhe 12 months before June 71 ot the yea� fhe deduction is to be eflecrive.
2) Mo6ile Nomes assessed under IC 6-1. 7-7: During the 72 months before March 2 of each �ear the in�/iv��dual wishes to
obfain the deducfion. �/%j�., ,CS�'".,a-�
See reverse side lor additional instruclions and
Name of a IiwN (owner or conVact buyerJ
i� ��
Is applicant Ne sole I o equitable owner?
I_4X8s � No
If name on record is difterent ihan that of aoPiicant, ii
ime ot conVact seller
Idress of convacl seller
applicant blind as defined in IC 72-1�
❑ Yes
the property used and occupied prirt
�
wng disVict
antl
for
❑ No
is hislher
vnth someone other than spouse,
with whom
Is the property in question:
❑ Real Property ❑ Mob�'le Home (IC E7.1-
i-72-12(b)? Is applicant disabled and unable to engage in any substantial gainful aclivity
as defined in IC 6-1.1-12-71(d)?
es ❑ No
�idence? Does Ihe applicanfs laxa6le gross income (or Ne preceding calen4et year
number I Legal descripUOn
- 3f� �loa-000. D8
Record number
❑ Yes
IMle certiry under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
oi
SignaWre of authwized representative
authorized representative
0