HomeMy WebLinkAboutDisabilty_Phillips°�" � APPLICATION FOR BLIND OR DISABLED PERSON'S couNTr TOWNSHIP reaR
r-- �; DEDUCTION FROM ASSESSED VALUATION
� ; � State Fortn 43770 (R6 / 4-04) �{
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Presuibed Dy the Department of Local Govemmeni Finance ��
In' aGon contained in this document is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-1.1-12-12(b). �-- File Mark
i�i!ucnoros: MAR 2 1 2007
To be filed in person or by mail with the CountyAuditor of the county where fhe propeRy is located.
Filing Dates: 1) Real,Property: Dunng the.12 months 6efore May 11 0( the year the deduction is to 6e effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months before March 2 0/ eg�year, i�ie+rn8ividual wishes to
O ❑ No
If name on record is difterent than that of applicant, indipte below
Name of contrad sell�er n
' l �
Address of contract seller Is the property in queslion:
❑ Real Property ❑ Mobile Home (IC fr1.1-7)
Is appliwnt blind as defined in IC 12-1-1-7(n) and IC 6-1.1-12-�2(b)? Is applicant disabled and unable to engage in any substantlal gainful activity
�/ as defined in IC 6-'I.1-12-1'I(d)?
❑ Yes l]Tlo es ❑ No
Is the property used and ocwpied primarity for hislFier residence? Does the applicanYS taxable gross income for the preceding calendar year
exceed 577,000? �
� es ❑ No �es �I No
Taxing district � Key number/ Legal descriptlon 6_ _/O�0/� �co�py�p� Page number
0 v ini�
OI(o -D(IColo-oa
I/We certi(y under penalty of rjury that the above and foregoing information is true and wrrect and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicanl Signature of authorized representative
. '
Address o( applicant �7 `(� p Address of authorized representative
o`?lo �. �+-. C`,� N .