HomeMy WebLinkAboutDisabilty_Longbonsd°"' .• APPLICATION FOR BLIND OR DISABLED PERSON'S
- . ; DEDUCTION FROM ASSESSED VALUATION
, State Fortn 43710 (R6l 4-04)
'•�• , Prescribed Ey Ihe Department of Locai Govemment Finance
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I atlon contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-Lb12-12(b). �-Fle M2rk�
i ucrioros: F�B 0 b 2007
7o be filed in person or by mail with the CountyAuditor o( ihe county where fhe property is located.
Filing Dates: 1) Real Pioperty: During the 12 months belore May 11 0/ the year fhe deduction is to be eKective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months 6efoie March 2 of each year the'individu'a!�-wishes to
� vrith someone other than spouse,
with whom
property in Question:
��S] Reai Property ❑ Mob�le Home (IC 61.1-7)
Is applicant disabled and able to engage in any substantial gaintul acfivity
as definedin IC 6-1.7-12-11(d)?
Does
❑Yes ❑No
gross income for Ne preceding calendar year
� Yes ❑ No
udrg district Key number / Legal descrip6on Record n
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INVe certiy under penalty of perjury that the above and foregoing informa io is true and correc an
of Indiana and owner of the aforementioned property on March 1, 20 _
of applicant
P�o �. �
of applicant
So
❑ Yes ❑ No
applicantwas a resident
Signature of authorized representative .
Address of auihorized representative
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