HomeMy WebLinkAboutDisabilty_Robb�4'��.� APPLICATION FOR BLIND OR DISABLED PERSON'S
.� .,- � DEDUCTION FROM ASSESSED VALUATION
Siate Fortn 43710 (R / 9-96)
S
,�,� � Prescribetl Dythe State Boartl ofTaz Cammissioners
Imormation contained in this document is CONFIDENTIAL pursuant to IC 12-1-7-7(n) and IC 6-1
INSTRUCTIONS FOR FILING:
To be filed in person cr by mail with the CounryAuditor ol the counry wheie the
ted during the 12 months before May 11 0/ the year the deduction is !o be e/%c
See reverse side lor additional instructions and qualifications.
exact
❑ Yes � No
name on record is dittereni than that of
contract
COUNTY TOWNSHIP YEAR
- � -� �� . File Mark
1-1 -12M(b�)�.. . -.
I IF1f� O 1 Z�UU
rtviSlOCa- _
licant blind as defined in IC 12-1-7-1(n) and IG 6-1.1-12-12(b)? Is applicant tlisabletl antl unabie ta
as defined in �C 6-1.1-12(d)?
❑ Yes Nf�lo
properry used and occupied primarily for his/her residence? Does the applicanYS tacable gross
exceed $77.00O?
es ❑ No
�di trict Key number / Legal description Recoi
C1� ��— cQf�=C2'��-S��?b
I vrith someone oiher
wiih whom
engage
❑ Yes
spouse,
.fifial gainful activiry
❑ No
in9 caienaar year
C9-�
I/We cer[ify under penal[y o( perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent oi Indiana and owner o( the aforementioned property on March t, 79 _
Signature of applicant
of
of authorized
of auihorized
7