Disabilty_RobbAPPLtCATtON FOR BLIND OR DISABLED PERSON'S
— DEDUCTION FROM ASSESSED VALUATION
-- srare r-«n, xt�io tx� i sosl
�+ Presamed by the DepaM�ent of Lotai Gavam�nl FnarKe
Infirtnation contained in this dowment is CONFIDEN77AL pursuant to IC 61.7-12-12(b).
COUNTY TOWHSHtP YEAR
File Mark
lNSTRUCTlONS:
b 6e frled in person a 6y meD with the CountyAud�tor of the county where the P�PB�Y is bcated.
Fdirx� Dates: 9) Real Property: Ourirg the year for wh�h the deduction is saght �g��! �
2) Mobile Homes assessed under !C 61.1-7 or ManufaCUred Homes not assessed as Real Pro � � Je 12J s befira
Marclr 31 o/each year the indNidual wislres to obtain Uie deduction.
See reverse side for additional instn�cSons and qualifiratbns.
Name W aPWkant ( or contrad 6tq'e/i
C .'J.
Is eppOrant the sde legal or Ie e. If No, what is hivlher srect shara of interest'? ��� ���U NTY AU D ITO R
es ❑ No
n re�e on re�e � em�n ma�, a� a a�m, a,a�e ce�
rmme mno-aa seear �
� '
AdCte�^ ot mntraa sellar (m�mber arM streat �MY siate, aiM cade) 1s tlie P�nY in quatiort
❑ � �+�Y 0 �'a�d
� � �c ��.�-�
�c nmm as aennm m ic iza-2s��i�? is a�rxam aisac�d ana wnoie m engaee N�r ��+ s� �v
as aennea m �c s-�.i-i2-i i�a�z
❑ Yes ❑ Plo Yes ❑ No
h tlx propertY uxd eM oxuPpd M�Y for hi�Rar resiAence? Does the awfi�anfs ta�m6la grass i�warna (or the Pre�dm9 �kMffi Year
exceee Efi.b007
❑ Yes ❑ No ❑ Yes No
disfirt Ke1+ munher I Lepal desaIDll� Remrd fwrtiha Pape number
a - �r-
UWe certify under penairy of perjury that the above and foregoing informalion is W e and correcl and that the appiicant was a res(dent
of Indiana and owner of the aforementioned property on March 1, 20 _
synamra or aaa�m nearess or avW�cam (numne. and aneer, cq: smre. a�a zia ade)
a neeressaauv�aee�+mu� (��.�,e��.o�:smro.�cvr��
306 KHs-� V�� �.