Disabilty_Douglas'� .,
APPLICATION FOR BLIND OR DISABLED PERSON'S r a
- . DEDUCTION FROM ASSESSED VALUATION
� � Slafa Form d3710 (R919-08)
�+ i
Prasaibe0 by Ne Deparimem of Local Goverrunanl Fnance
�nformatiom m�tainetl in this doaiment is CONFIDENTIAL pursuant to iC 6-1.1-12-12(b).
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INSTRUCTIONS: �jJ
To be filed in person or 6y mail with fhe CamtyAudita o/ fhe cwmty where tl�e property is bcated. v'"� '�' �
r;�irgoares: 1) Rea�propenyourirgtheyear�orwnicnu,eeeduc+;onissouync [� cn N C�Uf1,TY AUDITOR
2) MoDile Homes assessetl un0er IC 6-7.7-7 or Manulactwed Homes nd assessed as Real Propei�.'DLnrg e elve (12J monfhs belae
Marcl+ 31 W each year the individual wishes to obfain the deducGm.
See reverse sitle (ar adOifbnal inshucYions an0 qualifica(ians
Name W xGV�m (a»ner ar canfract Du}e0
�/_'1��1� �/��'C�/
Ls apptiraM Ihe sde Iegal or aQuilada ameR H No, M�at 6 tdvTer exad share d i�ne�est7 U amed with mmepie alher Ihan spouse,
inGimle with whom
❑ Yes ❑ No
M twne an temd is CiHeranl d�an Mal d applipnt iMicata bBbw:
Nartie o( mnraU se0ar
ACdrass d mntratl se0er (rvsnbrr an0 sbee�. tiry. sfaM. an0 ZIP o000) 6 Cie V W�M in GuBSiyti
fi22� � ASSES�
❑ ��y Modte� �e(IC67.t-7)
!s applicant �M as defined in IC 12-7-2-21(1)7 Is appicam disabled anE unable to ergage in arry wbsfamial gainful afiivity
as defined in IC G1.7-12-N1d)?
❑ Yes ❑ No ❑ Yes ❑ No
Is I�e V�WaM used and occu0� 0���' br �islher resdente? Dors the sPG��M's ta�ada 9�ss uxm�a for Ne G�eceQm9 mlerMar year
. es�e0 517.0001 '
� Yes ❑ No ❑ Yes ❑ No
Tazi(g dislricl Kay number / Legal desaiplbn Recnrd number Page number
% l0�0.�= `19,=�0/�=000.-•l-Sy- �
IIIWe certi(y under penalty of perjury that lhe above and foregoing information is lrue and correct and thal the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signat e W appiran ;/ Pddress of appluar� (numberaM streel, ary, sfa�, andZlPmtlo)
/`
%� � 35-6 D
SignaNre d aufhonzed repre entative AEdress o� aultwrized represenlatrve (nmriDCr aM s4xl, cify, sfafo, and LP code)