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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Sfafe Fam 43710 (R9 / 9-08)
Presuibed bY �e Dapanmenl d Lool Gwemmenl Finante
• Informatbm m�tained in Ihis tlocvment is CONFIDENTIAL pursuant to IC 6-1.1-12-12(D).
COUNTY TOVYNSMIP YEAR
Fil M
INSTRUCTIONS:
To be lled in person w by mai/ wifh the CamtyAuditor o/ fhe oounry whera Ihe prope�ty is bcated. N O V S 2 U 10
Filirg Dales: 1 J Real Piopelfy: Dunrg fhe year for whch Ihe deduction is sougM.
2) Mo6ile Homes assessed under IC &7.1-7 w Manulacturetl Homes nd assessed as Rea/ Property: Dunng the 1weNe (12) monfhs belae
March 31 d each year Ne indivitlual wishes fo o6fein the tlea�xlion. /� ,�-�
Seereverseside7oiadddionalinsWUionsa�Maualificafions. �'%t N //�
cantraaWyeO
k app6mm �he mle legal or
❑ Yes ❑ No I
tl reme m recartl is tliEerem tlan Nat tl app6canl iMimta babw:
J.'�.11.[��'��.
Pddrass N mntratl sa�ar (+u+nAri ard sbnoL �y. mm, antl ZIP oodo)
Lt appl'vaM EGnE az definetl in IC
Yes U No
share d imerastt
u� +.Ci:l%1
If o.meG wAh mmeone tlher Ihan sW�+m.
iMimle wRh w}qm:
r pWSM in V�sliart
R�a�v ❑ a,r�,�evi+ss�s�m
Mo6de Flome (IC G7.1-n
Ls appimrn disabiatl aM unable to mgage m arry wbstantial gvMul atlivey
as defined in IC Gl.1-12-71(d)7
❑ Yes ❑ No
'�'PROBM� aw`ped o� �h'- �sl _Oema? /1 / Ooes 1ha aGO��'s tasade grnss income br Ihe Vecedmg nle�Mar year
,�—F'{ji=� fl �Q'���-�'� ,1,am�e ar�ti?i a,�e sv.00m
� ❑ Yes ❑ No O
❑ Yes ❑ No
disleid I KeynumDer/LagaldesCriplbn Remrdnumber Pagenumbet
l�J�-/ c - �I •=%0:=�3�'�!�—�� (! y7f (7G-'� ,
IIWe certi(y under penalty of perj t lhe above and foregoing information is true and correct and Iha� Ihe applicanl was a residenl
of Indiana and owner of the afor menl ned property on March 7. 20
Pdtlress ol appliom (manOr�mitl sbeet. city, NaR, arqZlPmde)
�410 l�- Ca(Gns Y'25`(� w',nS(ow �
MErass of authorized reorasenlalive (n�anDrland sLeeG cify, sfafc, andLPCode)