Disabilty_Miller� � a APPLICATION FOR BLIND C)R DISABLEO PERSON'S c uNrr W YEAR
l. : DEDUCTION FROM ASSESSED VALUATION �,
\� Sta1e Fortn a3710 (R7/ 5-06) �
� Aesv�bed by the Departmn�t d Loral Cwanmen� F"vanre
�infortnalion contained in this dxument is CONFIDENTIAL pursuan� to IC 72-1-7-7(n) and IC 6-1.1-12-72(b). Q E��� ��]Q$
INSTRUCTIONS:
To be filed in person or by mail with the Counfy Auditor ol the county where (he p�operty is locafed `y�� ��
Filing Dates: i) Real Property.� Dunng the 12 months 6efore June 11 07 fhe year the deduction is to be effectiv�. ��6"'
2J Mobile Homes assessed under IC 6- 7. 7-7: Dudng the 12 months before March 2 07 ea��y��rhl�a�di,v�u���(o
obtain the deduction.
�
� ar contract buyerJ �
Q '1"� ���/✓i`e�'r— � /��y"` _ _
or equitable owner? I( No, what is his/her exaU share of interest?
❑ Yes O No
on record is diBerent than Ihat of aDPlicart
conVad seller
conVaU
I N'lth 50R120f1e othef illan 5(10use,
with whom
Is lhe property in question:
Rea� Property ❑ MolNle Home (IC 6-1.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.7-12-72(b)? Is applicanl disabled and unable to engage in any subsWnUal gainful activiry
, as defined in IC 6-1.1-12-11(d)?
❑ Yes ❑ No ❑ Yes ❑ No
Is the property used and occupied primarity tor his/her residence? Does Ihe applicanCs taxable gross income (or the preceding calendar year
exceed 517.000?
es ❑ No ❑ Yes ❑ No
axing trict Key number 1 Legal desc+iption Record number Page num6er
�-� � -ao -D�{ -3D0 -pd0. S 7 _ ooi
IIVJe certiry under penalty of peryury that the above 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, 20 _
o( authorizeA
of/� plpGwnt �-� � .: IAddress of authorized representalive
'�f L' v~,�� CV_�i7a.i».�_ Ti .. ..,. 1