Disabilty_McClanahan� APPLICATION FOR BLIND OR DISABLED PERSON'S cou HIP
DEDUCTION FROM ASSESSED VALUATION
• `� SlateFOrm437101R9/9-08�
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P`est�nbed by Ihe Depanmen� d Loml Grnsrtvnent Fnarr,e
�fwmafan contained in ihis doaiment is CONFIDENTIAL pursuant to IC 61.1-12-12(b). FiIB Ma
INSTRUCTIONS: q,(�
To be filed in person w 6y mail hi(h fhe CountyA�Uitor of fhe county ri�ere tlre property is bcate0. '�Vjj�
Fdirg Da(es: 7) Real Ploperly: Dunrg fhe year/or which the deduction is sotghG GIBS�N (�,��1T AUDI7Qii
2) Mobile Homes assessed uMerlC 6-7./-7 or Manufactured Homes not assessed as Real Roperty: Dunrg the hveNe /12) monfhs 6erore
Maich 31 W each year fhe indivitlual wishes to o6tsin the aeGuction.
See reverse side la a�itional insWdions qualifications.
Name VWi�-ant (awnrJa cnn t bu}eQ
%n c C�iiw-�
Is appiimm lhe sda lega eduilable , wAial e tds�her exad share of irrterasf! IF ownad wiih sortgone dher Ihan spouse,
indimta wilh whom:
Yes ❑ No
It rame m recvrd is di4arertl dan Nat of apWiran( iritlicata bebx.
Name d canrad se0ar
/dEress of mn0atl mGer (mm0or and sboat, U}; sbb. a� ZIP ootlo) Is Ne propeM in puastion:
❑ ReaIR'opertv ❑ AnrwaOVnssessed
Mohde Fiorne (IC G7.1-7)
Is applimnt OtiM as Eefined in IC 12-1-&21�7)7 ts applimnt disabled an0 unabla W ergage in arry wbstanlial I aaiviry
as defineC in IC G1.1d2-N(d)T
❑ Yes No Yes ❑ No
Is Na P�M usaE aM omPeA M����T/ Nhar rasEence? Doas Ure aPWicanfs tasade grnss inmme br Ihe P�ered'ug calendar year
exceed 577.0009
Yes ❑ No ❑ Yes o
Tazi`g dislncl Key number / Legal desaiption RecorE number Page number
� ab- 3 -�o-aDo.383-0 �
I/VJe certffy under penalty of peryury Ihaf the above and foregoing infortnation is true and correcl and thal the applicanl was a resident
of Indiana and owner of the aforementioned propeAy on March 1, 20
Signature dapplicant Pdtlress ot appticant (nimbera�M sbeeC city, state. arM Z/PCOtle)
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n ure of auN - ed rapresen�ative Pddress o� aufFnrueE representalive (numDCr aM shecf, rny, stafc, and LP cotic)