HomeMy WebLinkAboutDisabilty_Rexing��' "'° �}APPLICATION FOR BLIND OR DISABLED PERSON'S
; �DEDUCTION FROM ASSESSED VALUATION
(S .. , State Fortn 43710 (R6 / 4-04)
Presuibed by the Department of Local Govemment Finance
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In�- etion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-Lb12-12(b). File Mark ,
�w.
l 'UCTIOIdS: �. � � � �
To 6e filed in person or by mail with the County Auditor of the counry where the property is located. �
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be eHective.
2) Mo6ile Homes assessed under lC 6-1.1-7: During the 12 months before Maich 2 of each year the individual wishes to
obtainthededuction. - �Cl. � 6 2��5
ame of applicant (owner or conPdcf b
applirant ihe sole legal or equiWb
❑ Yes
name on record is different than that of
ame of contract seller
idress of wntract seller
applicant blind as defined in IC 12-1-1-
❑ Yes
the property used and occupied primar
es
udn 'tr't , ,
w"` V
l � C
/ �
I( No, whai is hisRier exact sha of � eresy?
� l.
No
ant, indicate below
n) and IC 6-1.1- 2(b)? Is appli
as defir
0
f� er residence? Does U
exceed
❑ No
with whom
ques6on:
Q
spouse,
��'FZeal Property ❑ Moble Home (IC 61.1-7)
: disabled and unable to engage in any substanlial gain(ul activity
in IC 6-t1-12-1'I(d)? _ �
number / Legal description
�/3 -���70 �o
C�es ❑ No
gross income for fhe preceding caiendar year
❑ Yes
I/We ceAify under penalty of peryury 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 _
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of auihorized represeniative
authorized representatrve