HomeMy WebLinkAboutDisabilty_HutsellAPPLtCAT10N FOR BLIND OR DISABLED PERSON'S
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Infortnation contained in Mis document is CONFIDENTIAL pursuant to IC 6�.1-12-12(b). '1 � O
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File Mark
'vSTRUCTIONS: �
filed in person or by mad wiih tfie CountyAuddw of Cie cainiy wheie U�e pnperty is located.
uu�g Oates:
AOQiess of mntraa seiler (numberantl sueeC �: state, aM LP coCe) Is the praperty in questron:
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Is appGrant bOrd as deNieO N IC 12-7-2•21(i)? Is appGCant d�sabled aM u�uble m engage in any su4stanRal ' adi�my
as aen�rea �n �c e-i.i-iz-i�(an
❑ Yes ❑ No es ❑ No
h n,s �o�rty „�a m,d o�,�ad w�y ror n;�me..�a�? oo� n,a ��r� u�we � �� r« n,a a�ms ��ffi r�
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❑ Yes ❑ No ❑ Yes o
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UWe certify der penalry ot perjury that the above and toregoing infortnation is Vue and corred and that the applicant was a resident
of Indiana and owner of Ihe aforementioned property on March 1, 20 _
Addrass of appfirairt (iwmberand cdy, ffite, and ZlPOOde)
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