HomeMy WebLinkAboutDisabilty_HenagerI� �
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' APPLICATION FOR BLIND OR DISABLED PERSON'S
i DEDUCTION FROM ASSESSED VALUATION
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Stale Fwm 43�10 (R9 /9-08)
PrasrlibeE by Iha Depanment d Lod Gmemnent Frwice
�nfarmation contained in this dowment is CONFIDENTIAL pursuanl lo IC 6-1.1-12-12(b).
lNS7RUCTIONS:
COUNTY TOYVNSHIP YEAR
File Mark
To be filetl in person o� by mail wvfh the CamtyAudi(or ol fhe munry whers the property is bcated. �����
Fdirg Dates: i) Rea! PropaAy: Dunrg fhe year Iw wh1ch the deductim �.s soughG �� ��
2) Mod7e Hanes assessed untler IC 6-7.1-7 w Manu/acfured Homes iwf assessed as Real Property: Dunrg the hvaNe (12) rtpntl�s be/ore
Mamh 31 d each year the irntlividual wishes to o6tain the deducL��m. D E �. R 7(111
See reverse side (or addAional insWdions aretl qualificafiams �
Namadavo���(o.,wiucmo-act Q C.'
�} GIBSON C �
Is apdimni lhe ade Iegai ar e9uitaN R M Na. wTat is his,her eract s 'urterest? C owneE with someaie other ihan svase.
inOimte w0h whom:
Yes ❑ No
M�me m recard is diQemtl ihan C�at d appfirant iMinte babw:
Nama W cmtraG
� v
Address d antract Oer (mmACr aM sbcet ci�: s�b�. aM LP ooEe) Ls Ne popery in Que9im
RealROpeAY ❑ MrWa�Y%�sed
Mo6de Fbrtie (IC G7.1-7)
Is applionl dinE as deEned in IC 12-7.2-21(1r7 is appliraN d'vsableC and unabla W a�gage in arry wbstar�lial gaifdul aclivity
as tlefinetl in IC 61.142-N(C)?
❑ Yes No Yes ❑ No �
6 Lha W WaM used ad omipiad OMaaY br hi4har resEerce? Doas It�e aPO�M's �asade grms inarne fw It�e 7��8 caleMar y�r
exrsed 51 ].000? .
Yes ❑ No ❑ Yes � No .
i3zing dis�ric� ' Kay numbar / Legal desviplion Record number Page number
�� a�-aD-aB-loo-aoo 3�-ooi
� IIWe certify under penalty of perjury lhat the above and foregoing informa[ion is W e and correcl and lhat the applicant was a resident
of Indiana and owner o( the aforementioned property on March 1, 20
Signa d appficaM fddress of appluanl (nenbri aM streM, cRy, sfaro, and ZIP code�
� \� �837 S S7�TC 2A 5 7 ����`��
Y 1�
naWre o(authonzed mpresantative Pddress ol aulhonzetl representative (nvmDCVaM sfinef, city, sfa(o, an0 LPcode)