HomeMy WebLinkAboutDisabilty_StolzAPPLICATION FOR BLIND OR DISABLED PERSON'S
- DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R9 ! 9-08)
�+ �
PrasQihed by Mie DepaM�ertl d Loml Govertunenl Fi�unce
�ormatiwi containcW in this doament is CONFIDEN7WL pursuant to IC 6-1.1-12-12(D).
� �fii't�'� 1. ��ii-, ��
i .". '�
� ' �
INS7RUCTIONS: C��.n V
To be filed in person or by mail K+fh tf�e CauntyAudRor o/fhe crounty wheie fhe poperty is bcated.
Frfirq Dafes: 1) Real Property: Dunrg the year /oi wh,ch fhe detluctqn is so�yht GIBSO C�1I
2) Mod7e Hanes assessed under IC 6-7.1-7 w Manufactured Homes nW assessed as Real Property: Owirg the fweTvB ��2�i�bfitRe
March 31 d each year fhe irnliviCwl wishes fo obtain the ded(.cfion.
See reverse sitle (or addifional insWCtions arM aualifiwtions.
Name d aVO�m (owmf � rmtrarl W�
6 aGGfimM Iha sde r ep�rilade mmeR I( No. 's hivT¢r ezaa share d iirtaraslA M owned with someona auiar Uwi sOwsa.
'udit�a wiU whom
Yes ❑ No
u name a, �ecwd is diEaren+ u,a d auobmnt �� 1e beb.-
f /
Name of se0ar
Address tl mntrad se0ar (num6m aM sboo�. tiry• sbb, antl ZIP oode) Is N pope�ly in queslion:
Rea�Prq�erty Q n.,rniaoynssessea
� AAohde Flame (IC 61.1-n
Ls appli�aM biinC as define0 in IC 72-7-2-21(1 n Ls applicant drsaDled and unable b ergage in arry wbstant0l gai`dul atiivity
as defined in IC 61.1-7247(d)?
❑ Yes ❑ No ❑ Yes ❑ No
Is Na P�PeM useG and ocwped o��M' br his/her ravdexs7 Does �he aPWicam's �asade grnss irxome for Uie G�eced"vg ralenCar year
az�aed 517.000? '
❑ Yes ❑ No ❑ Yes ❑ No
itg di trid Key number / Legal Oesaiplion Recptl numbar Page number
l � -J3- - o . o. 9 � �
IIWe certify under penalty of perjury that lhe above and foregoing infortnation is We and correct and Ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
sqna2ure ora�m ndaress or a�iram (nvnbe�a�0 sboet, ay, sfa�, antl ZlPcotle)
�, � y. � S ��i � 8c� �d Qa��-,�..1 G �✓5`���0
Signature d aufhonzeC represenlative AGErass of auttrorizetl reprasenHtive (nam0[raM slieel, cily, stato, antl LPCrode)