Disabilty_CanslerAPPLICATION FOR BLIND OR DISABLED PERSON'S courm� OWNSHIP r�
. -- DEDUCTION FROM ASSESSED VALUATION
� � � Sfam Form 43710IR9/9-08)
+ d
'PrasrnbeE by ttie DepartmeM d Lod Grnerturenl F(unce
�nformation contained in this doaiment is CONFIDENTIAL pursuani b IC 6-1.1-12-12(b). F,{�pti Mark
HrR
wsrnucnoNS: 1 ¢ Z���
b 6e filed in persan w by mad with We CounlyAudrlor o7 the county wfiera the /HOperty is bcated. �
Fdirg Dafes: i) Real Property: Dunrg fhe year lor wh�h fhe tletluctim is sought. �`
2) Ab6i/e Hdrres assessed untler IC G7. 7-7 or Manufachired Hortres not assessed as Real Property(��yN e Iw9� �Ns 6e7we
March 31 07 each year Me irMividual wishes to oblain the deducfion. "OV (,^ �
See reverse sde /� addrtronal insWCYqns ered qualificaGms. ouNT Y AUpI
Name d appGcartl (owner a cantiac( CuYoO _
1
Is applinnt Ihe sde iegal or i
If reme m �emrd'u diEarant
Nartre of cwH2d seDer
AtldtBSS o( lmhatl SBOeI (!n
No,
Yes ❑ No I
d appfionl inEicate eebw.
5 appfimM b6n0 az dafined in IC 12-7-2-21(1)?
statc. and
❑ Yes ❑ No
Is Ghe WuOaM usetl anE accupied PMw^lY br holher res0ente?
Yes � No
B1fHC16�12lB
Key num0er I Lepal desaiption
�( OMTIBd W1��1 SOfIBtlIB �i1Bl �dl1 SGd�SB.
ttIdIQ�B W1��I W�pfR
I �s m nwaM �, was�.
�RealRc�aH ❑ �^�Y%�
Mo6de Hort�e (IC 61.1-7)
b xPditaN disabled and unable In engaga in any w6sfaN¢I gaiNul aaivrty
as defiired in IC Gt.7-12-71(d)?
� �Yes ❑ No
ooes �ne aad�m•s �axaele gmss vwvna m. neceemg de�war year
es�ed f17,0009
❑ Yes � No
RecoN number Paae number
,i�i� aa��.2a�-
IIWe certify under penalty of perjury lhat lhe above and foregoing infortnation is We and coaecl and IhatLie applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
of appbam
W auUwrized mpresen�ative
Pddmss o� applipM (imnDM aM sbre4 my, statr:. and LP mdc)
AGErassolaulhorizsCrepeSenWive (numDpandsbecf.cRy,sfafe.andLProde)
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