Disabilty_Swope"' no
'`t
iS\'-/
� � -
�-
-APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form a377o (Ra / 10-Ot)
PresmbeA by ihe Department of Local Govemment Finance
COUNTY � TOWNSHIP YEAR
i �
�.�1 . I i .
�-mation contained in this document is CONFIDENTIAL pursuant to �C 12-1-7-1(n) and IC 6-1.1-12-12(b). YtleiRAafk�
"RUCTIONS: �� (j�
To 6e filed in person or by mail with the County Auditor o/ the county where the propeRy is located. ��tL� 1L�
Filing Dates: 1) Real PropeRy: During the 12 months be%re May 11 0/ the year the deduction is to 6e eflective. J ��
2) Mobrle Homes assessedLnder IC 6-1.1-7: Behveen January 15 and March 31 0/ the year �e de��ion �s t�s��f/ective.
��
See reverse side for additional insfructions and qualifications. J� , ��%
or contract
Is applicant ihe sole tegal or equitable
❑ Yes
If name on record is differenl than that
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)?
❑ Yes ��
Is the property used anA occupied primarity for
❑ No
G
indicate with
Is the property in question:
spouse,
��'F%al Property ❑ Mobile Home QC 61.
Is applicant disabled and unable to engage in any substantial gainful aaivi
as defined in IC 6-1.7-72(d)? /
�s ❑ No
Dces the applinnt's taxable gross income tor the preceding wlendar year
exceed 577,000?
❑ Yes C�
Key number / Legal desaiption
number �Page number
I/We certify under penalty of perjury that lhe 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 _
.��