HomeMy WebLinkAboutDisabilty_NelsonI�=� '-:.
°�"' kPPLICATION FOR BLIND OR DISABLED PERSON'S
= �; DEDUCTION FROM ASSESSED VALUATION '
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� State Fortn 437t0 (R3/ 8-00)
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�' PreSCribed by the Sate Board of Tax Commissioners
rmation wntained in this document is CONFIDENTIAL pursuant to IC 72-7-1-1(n) and IC 6-1.1-12-72(b).
IN�TRUCTIONS FOR FILING:
To be filed in person or by mail with the County Auditor of the county where the properiy is loca-
ted dunng the 12 months befo�e May 11 of the year the deduction is to be effective.
See reverse side fo� additional instr�ctions and qualifications.
OUNTY I TOWNSHIP YEAR
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SEP 1�� ��8d
GIB/�'JTY AU�
Name of applicant ( w er or conVact bvyer
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Is applicant the sole I gal or equitable owneR I( No, what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on record is diBerent than that of appliwnt, indipte below
Name of contrect selier
Address of contraci seller
Is applicant blind as defined in IC 12-1-1-1(n) and IC 61.1-12-12(b)? Is applicanl disabled and unable to engage in any antial gainfut adiviry
as defined in IC 61.1-12(d)? es ❑ No
❑Yes ❑No
Is the property used and occupied primarily f s/her residence? Does the aoplicanYs taxable gross income for ihe preceding calendar year
� exceed 517,000?
es ❑ No ❑ Yes ❑ No
Tarzing istric[ Key number / Legal description Rewrd number Page number
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I/We certify under penalty of pery'ury that the above and foregoing infortnation is true and corred and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
S' nature of applicant , Signature of authorized representative
Ad ess appliqnt �1�� `1 � Address of authorized represeniative '
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