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° APPLICATION FOR BLIND OR DISABLED PERSON'S
-- . DEDUCTION FROM ASSESSED VALUATION
. semFOrmaa�io�sis-m�
's I
�+ PrescnEeE by ttie Departmenl d Loml Govemment Firance
i
�formatiom m�tained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
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INSTRUCTIONS: `%9jA� n//_
p�r Nro��,
To be filed in person w by mail Hith the CountyAudtw o/ fhe wunry whera tl�e poperly is locatetl.
Filing Dates: 7) Reat Property: Dunrg the yearlw whic/r fhe deduction is soughL GI980N CO NTY AUDITOR
2) Mo6ile Homes assessed uMer IC &7.1-7 or Manufactured Homes nW assessed as Real Hoperty: Dunrg fhe AveNe (72) monNs befae
Marclr 31 0/ earh year Ihe ilulivitlual wishes to obtain Ure deducfion. �� '
See reverse Siae lor aOddional inSWCtiOns a� qualifications.
Name of aVP�M (owrr� or caWnac^t bvyeiJ
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Is apotioM sak lepal ar eVU4 ownaR H No, whal o hisfhar esaG shara d interest? C awrred wilh someane aher Nan svwse,
u�dimte vrifh Wrom
❑ Yes ❑ No
C rema on reard is �areN than Nat oF apptiranL iMirate bebw:
Nama d cantrad seuer
AOdress W wntratl seBa (rnanbe�iand sbuc�. tiry. sfam. aM LP m0o) �is N/e properry in questio2
�F2eaIH'opeM1Y ❑ Mrw�Y%�sseaed
Mohde Hortie (IC fr1.1-7)
Is appliranl bGnE as aeFnetl in IC t2-7-2-21(t/.� Is appi�am aLSaoletl and anade to e'gage in arry w6stamial gaiMul aaivdy
as defined in IC 61.14241(d)?
❑ Yes ❑ No � ❑ Yes ❑ No
Is Ma p�opeM �� � ar�P� P�^anly br hi4her resdenca? Does Ihe a0d�nfs tasade gross inmma br Iha yaraE"ug talendar yaar
exoeeE 517.0009 '
Yes ❑ No ❑ Yes ❑ No
Taxing distrid
a residenf
of Indiana and owner of the aforementioned property on March 1, 20
Signatura of appl'canl Pddress of appliaM (�nrriber aM stree( aty, slale, arM Z/P mtle)
� ' " 99D2S 55d G � s .� y�63�
Sgnature d aulhonzed rapresemative AnCress ol authwiud represent�ive (numbrr aM sheci, cey, sare, ar0 LP co0e)