HomeMy WebLinkAboutDisabilty_Richardson�"" : APPLICATION FOR BLIND ISABLED P SON'S
; DEDUCTION FROM ASSES
S ; State Fortn 43710 (R6 / 4-Oa) .
PresaiDed by Ihe Department of Local Govemment Finance
COUNTY TOWNSHIP YEA
�i ln �
In' ",ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.�-12-12(b). f' File Mfl rlii 9 �)
I,�tUCTIONS: �L .gJ'
To 6e filed i� person or by mail with the CountyAuditor of the county where the property is /ocated. �U N Q 9 Z��6
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 of the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 0l each yearlhe individual wishes to
obtain the deduction. `-7-�a� ��
See reverse side for additional instructions and qualifica6ons.
O
of applicant (owner or contrect buyer o'
icant the sole legal or equitable owner? If No, what is hislher exact
❑ Yes O No
name on
Name of contrad seller
ihan that of applicant, indicale below
Aicant blind as defined in Ic 12-L1-7(n) antl IC 6-7.Y12-72(b)?
❑ Yes ❑ No
property used and ocwpied primarily for his/her residence?
� ❑Yes �No
� disVict Key number / Le
Cb_a -,
I vrith wmeone other than spouse,
with whom
: the property in ques6on:
❑ Real Property ❑ Mobile Home (IC Et.
Is appliwnt disabled and unable to engage in any subslantial gainful activity
as defined in IC 6-1.7-12-1�(d)?
OYes ❑No
Does the appliwnYs taxable gross income for the preceding calendar year
exceeC 517,000?
� Yes ❑ No
description Record number Page number
7��29_ c�
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
of authorized represenWtive
auihorized representative