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�A� APPLICATION FOR BLIND OR DISABLED PERSON'S couHrv TOWNSHIP vena
; i��; DEDUCTION FROM ASSESSED VALUATION
State Fortn a3710 (R7! SO6)
�i
Prescrd>ed by Ihe Departrnrnt af Laal Govemment Finance
�nfortnation contained in this document is CONFl�ENTIAL pursuant to IC 72-1-1-1(n) and IC 6-t.t-72-12 . Fil � M
INSTRUCTIONS:
To be (led in person or by mail with (he Coun(y Auditor ol the couniy where fhe p�operty is located.n�^ 7 �� Z007
Fil(ng Dates: 7J Real PropeRy: Dunng the 12 months betore June 71 0l the year the deductlon is to Di�eNe i.
2) Mobile Homes assessed under IC 6-L 1-7: During lhe 72 months betore March 2 0( e� year� �pdividual wishes fo
obtain the deduction. a�„ /$�a�,
See reverse side (or additional ins
Name o( applica� (owner or conVact
appliwnt
owner?
❑ Yes ❑ No
name on record is different than that of applican4
contract
Is appticant blind as defined in IC 12-1-7-1
❑ Yes ❑ No
ihe property used and occupied primarily for hls/her
❑ Yes ❑ No
district
1.7-
exact share of
owned with someone olher than spouse,
dica[e with whom
Is Ihe property in question:
� O Real Property ❑ Mob�1e Home pC G7.
Is applicanl disabled and unable to engage in any su ntial gain(ul activi
as defined in IC 6-1.1-12-N(d)?
es ❑ No
:ey number / Legal descrip6on
_ �Q _ L/f�/1 .tlt�
ihe applicanPs taxable gross
�.d 317,000?
❑ Yes
Page number
I/We certiry under penalry of perjury thal the above and foregoing information is trve and correct and that the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20 _
of applicam
of authorized
representative
1�
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