Disabilty_Lamar1
i.
:+� i
APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
$tala Fpm 43710 (R9 / 9-08)
� a�• Prescnbed by Ne DePaM1rtrenl d Loml Go.emmant France
Sfwma�iom m�tainetl in this doaiment is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
lNSTRUCTIONS:
COUNTY TOWNSHIP YEAR �
� � �
JAN 6FIe LUII
To be lrled in person or 6y mail wilh the CamtyAuditor of fhe caunty where ffie propeAy is located. C.�.
Fdirg Dafes: 1) Reel Property: Durirg the }rear far which the deducliwi is sought.
2) MoWe Horrres assessed under IC Gf. f-7 or Manu/acturaU Harres rwt assessed as Real ProoeM.�gN C�OU NT'Y A D TOR�s beiae
Ma�ch 31 W earh yearMe irxlivitlual wishes to o6lein the deductian. G�B�
See reverse si0e /or adtlAional instiudions ared qualifiwtion
Narna of zVG�N (owm or rontrxt Duyer)
Is appfimM Iha sda IeQal ar eQUitabla wneR H No. wnal is hdher eua share cf imerest? M owned wiU somaona olher Ihan spou�.
inOiWe wilh whom:
❑ Yes ❑ No
H nama on retord i5 Eifl�Beent Nan Uia1 d a�6mnt iMicate bebw:
Name of cavrar� s�ar
Address d mntrad xe0er (ipurNOr aM sbueL �: sfa�. and LP codo) Is Ne ptoperty in que�+�.
RealPropertv ❑ nnruanv/�sseaed
Mo6ae Hort�e (IC Et.t-�
Is applimM bfiM u Eefined in IC 12-7-2-21(1 �? is appiioM diubk�A and unaEle to aigape in arry sudsfan� gaiAul aUiviry
as defined in IC 61.b12-11(E)1
❑ Yes ❑ No ❑ Yes ❑ No
Ls Lhe p�opeM � and ocwped pri��rBy (or hi4her resdence? Does Ihe applicanTs W+abla gross incoma fur lhe precedug nlarWar year
exmed 517.000? .
�Yes ❑ No ❑ Yes ❑ No
distnd Key number I Lepal Eestripibn Racwd number Page number
� �o -Oa -sq-o33 _000. ao -oi 9
IIWe ceNfy under penalty of perjury Ihat lhe above and foregoing information is We and corred and Ihat �he applicanf was a resideN
of Indiana and owner of lhe a(orementioned property on March 1, 20
sy� �r�ofappbom nedresso�appti�am (nm+b�arWStreef,My,sfafc,arMZ/Pmtle)
L
SgnaWre W auUiarizeA rapresenlalive AECress o author¢ed reprasentative (numGrand sheef. ciry. sfafe. and ZIP code)
y-�� �c�