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�"o� APPLICATION FOR BLIND OR DISABLED PERSON'S
,;� `1 DEDUCTION FROM ASSESSED VALUATION
,� . State Fmn a3710 (R7/ SO6)
�_�c Prest�ed tlieDe
by partman d Local Gwemment Finance
COUNTY TOWNSHIP YEAR
� � � q �D
nfortnaUOn contained in this documeni is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and �C 6-1.1-72-12(b). JUN 8 2009e�
NSTRUCTIONS:
To be /iled in person or by mail with fhe Counly Auditor ol Ihe county where (he property is locafed.
Filing Dates: 1) Real PropeRy.' Dunng the 12 months betore June 17 of the year the deduction is to be �%f�'�Gg �Q
2) Mobile Homes assessed under IC 6-1.7-7� During the 72 months before March 2 0/ each yg� the�vidual wishes fo
obtain the deduction. 01880N COUNTY AUDITOR
See reverse side (or additional instructions and ualificafions.
Name of applicant (owner or contract buyer)
: on recora is amen
of conUad seller
cs of conVact seller
icant Wind as defin�
uitable ovmer? I If No,�4hat is hisRier exaG share o( interesi?
❑ Yes ❑ No
an that o( applicant, indicate below
and IC 6-1.1-12-12(b)?
❑ Yes ❑ No
Is ihe property used and occupied primarily for his
Yes ❑ No
C,� .� _ _ ' ✓
I wim someone other Man spouse,
with whom
Is lhe property in queslion:
��I Real Property ❑ Moble Home (IC G7.7-7)
t disabled and unable lo enqage in any subsWnfial gain(ul activiry
in IC 67.7-12-1'I(d)?
Does the applicant's
exceed 577,000?
� number I Legal description
�-aa -�S �-oo _ doD, 9
gross income (o
Record number
�Q _�n
❑ Yes ❑ No
r the preceding calendar year
❑ Yes O No
IIWe certify under penalty of perjury that the above and foregoing information is true and covect and that lhe applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Si nature of apptirant
z 1 .
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( Addr� s appficaqt
��y �� �ii•
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Signature oi
representative