HomeMy WebLinkAboutDisabilty_Harper�
APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form d3710 (R919-08)
PresaibBC by NB Depa��menl d loml Gmemmenl fl'ance
� In(ormation oonttined in Ihis doaiment is CONFIDENTIAL pursuant W IC 6-1.1-12-12(b).
INSTRUCTIONS:
COUNTY TOWNSHIP YEAR
File Mark
JUL 1 3 Z010
To 6e filed in person w by mail with Ure CounlyAWita o/ the oounty wheie the property is locafetl.
Fdirg Dates: 7) Real Properly: Dunrg the yeai (a whkh Ne deduction is sougM. `-7� �/��
2J Mobile Homes assessed under IC 67. 7-7 or Manulactured Homes nof assessetl as Real Property: iJHrfify77�e b eh2�) monNS belpe
Maich 31 of each year the individual wishes to obfain the deducliar. �% J
SeeieversesitlefaadddronalinsWdionsariOqualifications. u�c�vrv'v'JVfV:T nuuii�n
Name d aGP�d (owrur a cont�ac! drye0
� � �
� a�a�m ma ��i or �n� o.,,ea M No, whai o Idsfiar exaG shara d iM tl owneA with olher Utan spouSB,
'uMimle with
❑ Yes ❑ No
M rame on retON i5 diRerenl �han tt�at d appfionl ���Ie Oebx'.
Nanie d caniratl
Pddress d wn Oer (rumDer ad sboct �Y. sble. aM ZrP wdo) Is Ne propeery in Quastion:
❑ Re��r�v ❑ a,rwaevnsse�ed
. r.tobae tiort,e (�c s-t.t-7)
Is apptiraN bGnE as EabneA in IC 12-7-2-21f 1y! ��q�m e�c�a a,e �� m�y� ��y A,�rarnd y�r�na aa�y
� d��a � ic si.�-�z-�ilep
❑ Yes L+}rvo es ❑ No
Is Uie propeM � antl ompaC pnmariy br hislher restlance? Does Ure aod�M's tazade gross incame 1or Ne prereLing olendar yaar
exmeE f17,000? '
Yes ❑ No ❑ Yes ❑ No
disl�ici Key number / Legal desaiplan Remrd number Page mimCer
��i�/_� �d'=�Q�Q�3- _ ' d%
IIVJe certify under penalty o( e� ry[hat the above and foregoing information is troe and correct and that the applicanf was a residenl
of Indiana and owner of lhe ementioned property on March 1, 20
Signatureofappfimni Addressofappizant (ivmbera�dsbeet.ofy.stam.andZlPmde)
� 3zz.s. c.',6��,s-F Dw��4N�e ci+�i,�a
SignaWreNainhanzedreo��iative MCressola�lhorizedrepesenlative(numDOranOS ,cily,5afe,anOLPCOdc)
n