Disabilty_Broshears'°" APPLICATION FOR BLIND OR DISABLED PERSON'S couNTr TOWNSHIP renR
; -� - � DEDUCTION FROM ASSESSED VALUATION
, l• ^ State Fortn d3770 (R614-04)
� Prescribed by ihe Depanment of Local Govemment Finance ��
\ ,
Ir 6on contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b) g�/ p r u° 2
I�UCTIONS:
To be (led in person or by mail with the County Auditor of the county where the property is located. MA`( 1 9 20�6
Filing Dates: 1) Real Property: During the .12 months before May 11 0/ the year the deduction is to be e/fective.
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months 6efore March 2 of each yea� the individual wishes to
obtain the deduction. ���`^ ��"�i
or
name on record is difterent than that
as
❑ Yes
❑ No
❑ No
as
�f ownea vnth someone
indiwte vrith whom
Is the property
spouse,
❑ Real Property ❑ MobBe Home (IC 61.1
: disabled and unable to engage in any
in IC E7.1-12-17(d)?
Does the aDPlicanYs taxable gross inwme
exceed $17,000? �
� � / � �.
number
as ❑ No
preceding wlendar year
❑ Yes
number
I/We ceftify 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 _
� li R 3 /SQ,- 3