HomeMy WebLinkAboutDisabilty_Krieg- ""' APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr P Y
. - . DEDUCTION FROM ASSESSED VALUATION
Sm� Farm s3770 (R914O8) -
�+ J
• Prasaibed bY �e Deparinienl tl Loml Gmemnent Financa
�;;ormation cootained in Ihis doaimeN is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
INSTRUCTIONS: C � n� �y�.
To be filed in rsm or b mail Hith the Coun Auditof ol fhe coun wlrere Ihe �� ����
PB Y �Y �y properly is bcaled. (,�
Filirng Dates: i) Real PropeAy During fhe year /or which the deducfion is soughG �p N!;r��� v
2f Mo6i/e Hwnes assessed under IC 6-7.1-7 or Manufactured Homes not assessed as Real Properiy: DuC'nrtgY��nvaxry �j�av �
Ma�ch 31 0! each year tlre i�ividual wishes fo o6tain fhe deductian. •
See �averse side /w adOdional i ctions arM qualifica(ions �
Name of aV � M(owxr or cmbad rJ
0
!s app � n Na stle r eQUitable ownaR M N, what - er asad shara d'mteresl? C owried wifh mrtema dher Nan spouse,
indimte with whom:
❑ Yes ❑ No
tl �wne m remrd is diRereM than lnat d app�icanl indicate Debr-
Narne d mnlracl se0er
PEdress of mnVatl se0er (iuunbri and sbcet. ci�: sbto. aM ZIP coda) Is popeM in Gue`�ion:
RealFroperty ❑ nnrn,euywssessed
Md�ile Horne (IC E1.1-7)
I5 applimnt WirW as EefineC in IC 12-7-2-21(1)? Ls appiicam disableE anG unabla to eeqage in a�ry wbstaMial gaiMul adniy
as defirred in IC G7.1-12-71(d)?
❑ Yes ❑ No ❑ Yes ❑ No
Ls Ne V�M useE aM accuPreA 7M�M' br �i.4her rasderrce? Ooes lhe apd����'s lasable grnss itrmna for Ne �/eteEinB ralendar yrar
eYwed f17.000? '
❑ Yes ❑ No ❑ Yes ❑ No
a.�ing'lriG Kaynumber/Legaldesaipian Recordnumbar Pagenum�er
- �- � -��. � � - Q�
IIWe certify under penally of perjury thal lhe above and foregoing informa6on fs We and cortecl and Ihat the applicanl was a resident
of Indiana and owner of the aforementioned proper�y on March 1, 20
Signature of a M Adtlress af applimrit (nunbei mN sbeet, My, sfa�, aM ZIP mtle)
X ^ �-3 s ' � , � y
Sig luraoia zeerapresenlalrve � Mdressotauthwizetlrepresentalive (num andsfrect,cify,9af0. LPCOOC)