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APPLICATIONFORBL DISABL RSON'S cour+TV TOWNSHIP renR
_� ., DEDUCTION FROM ASS _� . - AT�ON
Siale Fortn 43710 (R7 ! 5-Ofi)
.�_ �i
"" Presaibed by �he Depamneni W Loql Gwemment Finaeue
�� Information contained in this document is CONFIDENTIAL pursuant m IC 12-1-t-1(n) and IC 6-7.1-12-12(b). ile M
�NSTRUCTIONS: S'EP
� To be Iiled in person o� by mail wifh !he County Auditor o7 the county where lhe property is locafed. 2 e5 1009
Filing Dates: 7) Real PropeRy: Dunng the 12 months before June ll of the year the deduction is to ftecrive-
2f Mobile Homes assessed unde�lC 6-1.7-7: During the 72 monfhs before March 2 of a� i dividual wishes fo
, obtain the deduction. G/$gpN COUNr., �
See reverse side for additional instn�r.finns and n��alifi�ai�.,,,�
Is
of�plicant (owner or confract
soie
`}7� Yes ❑ No
name on rewrd is diflerent an that of applicant,
ame ot conVacl seller
ddress of conVacl seller
applicant blind as defined in IC 72-1-1-1(n) and p
I/We certify under penal
of Indiana and owner of
❑ Yes ❑ No
ied D�marilv (or hislher
❑ Yes ❑ No
is his(her exacl share
If owned with mmeone
u�dicate vrith whom
Is the property in ques[ion:
spouse,
�� Real Property ❑ Mobile Home QC G1.1-7)
Is appliwnt disaWed and unahle to engage in any subsWnUal gainful activiry
as definetl in IC 6-7.1-12-11(d)?
❑ Yes O No
Does lhe applicanPs taxaGe gross income for the preceding ntendar year
ezceetl 517,000?
i�i� /o� �/. /9G
❑Yes ❑No
�mber
`perjury that the above and foregoing information is true and correct and that the applicant was a resident
aforementioned property on March 7, 20 _
authorized representaWe
appGwnt
ot
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