HomeMy WebLinkAboutDisabilty_Shackelfordr1 . . .
��„n APPLICATION FOR BLIND OR
a �.'°.g DISABLED PERSON'S DEDUCTION
FROM ASSESSED VALUATION
�� • � � State Form 43710(1-90)
��'°`: �., prescribed by the State Board of Tax Commi
4-E53
County Township Year
ssioners
� I
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional quaNfn ations and instructions. n n
( 1 ,.
Applicant (Owner r coptract �y r ) I t �� f� m
(/ Il
�yes � no
If name on record differenl
Name of contract seller:
Address of contract seller:
Is applicant blind as define
IC 6-1.1-12-12(b)?
� yes � o
or IIf no,�ahat is his/her exact share of
interest?
12-1-1-1(n) &
:s the pro rty used and occupied primarily for his/her
resid e?
yes � no .. _ .., _ _
w . ---•
ii�
�
File Mark
�����
�E� 9 1992
with someone othe
indicate with whom.
Is the appli isabled and unable to engage in any
substa ' gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Does the applicanYs t le gross income for the
preceding calend ear exceed $13,000?
� yes no
Taxing District Key Num er/ Description Record No.
l
� � � Page No.
.
I/We certify under penalry of perjury th t the abo and foregoing information is true and correct and that the applicant
was a resident of Indiana and owner of the aforementioned property on March 1, 19
Authorized Representative (by executed Power of
Attorney)
GI
?ss � 3plicant D /, I/� I- � Address of Representative
j��j W e 7 S �� 7