Disabilty_Knight�'°-4 APPLICATION FOR BLIND OR DISABLED PERSON'S
r'. -,i DEDUCTION FROM ASSESSED VALUATION
\,,� 51ate Fortn a3710 (R7! SO6)
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Prewibed 6y Ihe Departn�ri W Laal Gwemmrnt Finance
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�nformation contained in this document is CONFIDENTIAI pursuant to IC 12-1-1-1(n) and IC 6-1.142-12(b). �UN 1�il��Ql�c
NSTRUCTIONS: ' \
To be �led in pe�son or by mail with the County A�difor ol the county where the property is locafed. �p-y�,/, -
Filing Dates: 1 J Real Property: During fhe 72 months before June 17 of the year the deduction is to be eNe"criv� ��
2) Mobile Homes assessed under IC 6-1. iJ: Ouring the 12 monlhs 6efore Ma�ch 2 oC��BC))�gTQRl1LFiMiJM'll311fEa8hes lo
obtain the deduction.
See reverse side lor additional instructions and qu'�lifica6ons.
�Name of aoPhwnt (owner o� contract bwed .-, �
legal or
name on record is difterent
convac�
Yes ❑ No
that of applican�
Is applicant blind as defined in IC 72-1
❑ Yes �No
property used and occupied primarily (or his/F�er
❑ No
what
with wmeone other than spouse.
vri�h whom
Is ihe property in question:
Real Properfy ❑ MobOe Flome QC 61.1-7)
1.7-12-12(b)? Is appiicant disabled and able o engage in any substantial gainful activiry
as defined in IC 6-7.1-12-11(d)?
❑ Yes ❑ No
�esidencel Does Ihe applicanfs taxable gross income for Ihe preceding calendar year
exceed 577,000?
❑ Yes No
�.y number / Legal tlescription � Record number Page number
G /13 / aao o�uo..,3�3 _o 0
I/We certify under penalty of perjury that ihe above and foregoing infortnation is true and correct and that the applicant was a re2'Jent
of Indiana and owner of the aforemenlioned property on March 1, 20 _ ,
ofauNOrized
l /L._
representative
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