HomeMy WebLinkAboutDisabilty_FieldsAPPLICATION FOR BLIND OR DISABLED PERSON'S r s ia , r�
- DEDUCTION FROM ASSESSED VALUATION
Sfale Fam 43710 (R919-OB)
.� � �
+ Prasaibed by tl�e DepanrneN d Loml Grnemrnent Finance
�famatbm m�tainetl in Nis doaiment is CONFIDENTIAL pursuant to IC 6-1 J-12-12(b). � File
WSTRUCTIONS: �/
To be file0 in person or by mai! rith Ihe CamtyAudita o/ the caunty wheie the pioperly is /ocated. %/�G,,,, �'.'!,i�-rf
Fdirg Dates: 7J Real Property: Dunrg the year lar wh�ch fFre deducGm is soughG �� Q :/
2) Modle Harres assessed under IC Gf. f-7 or ManWactured Homes nW assesse0 as Realp�r�ad�, "�e=� �riafi9�s belwe
Maich 31 0/ eech year Ihe i�ividual wishes to obfsin the Ueduction. �'����� r�
See reverse sitle l� addifional insWCfions and qualificafions.
Na�redav m(awie.orcanhaaWicvJ -�!.��
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Is applimrq ihe sale legal w epuitade owreR M No, W�at is his/her e�acl shara d imeresY! C owned xilh someoria aher Ihan spausa,
�tale with wtqm:
❑ Yes ❑ No
C name m recad'a diQarent Ihan Uwt d appfrartl, indicata balrnr.
Nanre d canlraG se0er
AOdrass d mnM1atl seGer (nim0or an0 slreeL m1'. sta�. and ZIP mde) Ls ppp¢rty in pueyion:
�RealProperty ❑ MrxiallyAssessed
Mohde Hort�e (IC 61.1-7)
ts applimN bGM as Ge£neE in IC 12-7-2-271i7? Is applimm disabled aM unade lo angape in airy substaNial gaiNul atliviry
as defined in IC 61.1-1247(d)? �
❑ Yes �No ❑ Yes ❑ No
Ls Ne propaM � anE ocwpied pimardy for hl4her r¢siderca? Dces Ihe appGcaM's ta�ade g(oss incortre br Ihe precetling nleiWar year
eztaeE 517.0001
[�'Yes ❑ No ❑ Yes ❑ No
irg dislricl Key wmber / Legal desuiplion Remrd number Page numCer
� (o -l3 _/3 _ 30 0- ooa. 1 bb �
IIWe certify under penalty of perjury that lhe above and foregoing infonnation is true and correc[ and thal the applicant was a residenl
of Indiana and owner o( Ihe aforementioned property on March 1, 20
Sign� ra applicaM � Address ol appliorh (iwmbe�antl sVeef, city, sfale, aM ZlPwtle) _
��p� 5 • �O �S E . �,'4 K/-ft-s�!/� �iT �f7� �o
Signatura d a AGdress of authorized representalive (numDV antl sbeef, cXy. �atc. and LP codh) ,