HomeMy WebLinkAboutDisabilty_France'- �"'"'"a APPLICATION FOR BL�ND OR DISABLED PERSON'S
' DEDUCTION FROM ASSESSED VALUATION
a•' �� � State Form a3770 (R4/ 70.07)
S:,: '� Prescsihed by ihe Department o} Loral Govemment Finance
COUNN I TOWNSHIP I YEAR
I^`^�nation contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-7 (n) and IC 6-1.1-12-12(b). � ��File Mark! �;��
�-RUCTIONS: f! {' i_�'°� � ;,
o be (led in person o� by mail with the County Auditor o/ the county whe2 the properfy is locafed.
Ji . « � 1�J Jl�'
Filing Dates: 1) Real Property: During the 12 months be/ae May 17 0l the year fhe deduction is to be e/fecti�vg, N� 2,�nn�
2) Mobile Homes assessedLnder 1C 6-1.1-7: Between January 15 and March 31 0/ the year the 7educhon Fs+t� e effective.
See ieverse side for additional instructions and qualifications.
Nameofapplipnt(ov e qrcon6;acfkuyer) _�_,
Is applirant the sole legal or
If name on rewrd is diBerert
Name of contract seller
�
4ddress of contract seller
Is aooiipnt blind as defined
Yes ❑ No
that of applicant,
�
�
�2-1-7-1(N and II
❑ Yes
Is the property used and ocapied prirr
Yes
If No, what is his/her ezact share of interest?
YJ No
>
for his/her residence?
❑ No
Keynumber�
c� /;
GI3SpN C��Ur;1Y AUDiTOR
If owned with someone other than spouse,
indicate with whom
Is the property in question:
��I Real Property ❑ Mobile Home QC 61.1-
Is applicant disabled and unab e to engage in any substantial gainful acii0ity
as defined in IC 67.1-72(d)?
�Yes ❑ No
Dces the applicant's tauable gross income fo the preceding calendar year
exceed 577,000?
❑ Yes �t'No
-oasa y
I/We certify under penalty of perjury that tne above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
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