Disabilty_Hessler�
�^•°''4 APPLICATION FOR BLIND OR DISABLED PERSON'S couNrv TOWNSHIP venR
a- ? DEDUCTION FROM ASSESSED VALUATION
i,__..
.. State Form a3710 (Ra / 70-07)
S:'�O Prescribed by the Department ol laal Govemment Finance "�'
��nation wntained in this document is CONFIDENTIAL pursuant to IC 12-t-1-7(n) and IC 6-7.1-12-72(b). �I ark�
fRUCTIONS:
To be frled in person or 6y mail with the County Audifor of the counry wheie the property is located. SEP Q 9 20�2
Filing Dates: 1) Real Property: During the 12 months 6e%2 May 11 of the year the deducfion is to 6e e(fective. �
2) Mobile Homes assessedLnde� IC 6-1.1-7: Befween January 15 and March 31 0l the year th/e/-deducf�ion� ijs to ` eBect%'pe
See ieverse side fo� additional instroctions and qualifications. K„ „y ✓)Y'J 1na
u
Is applicant the soleQ2gal or
es ❑ No
name on record is difrerent than that of applican
No, what is
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-1
❑ Yes LyYNo
Is the property used and occupied primarily for hisRier residenc
�- 15C1'es ❑ No
Ta�ng disVict _ Key numbi
share of interest? If owned with someone other than spouse,
indicate wiih whom
Is the property
I❑ Real Properiy ❑ Mobile Home QC 61.1-�
; disabled and unable to engage in any subsWntial gainful activity
in IC 6-1.1-12(d)? ��
ti,'Yes ❑ No
0
gross
❑ Yes �
year
I/We cerMy under p�rfalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant' Signature of author"¢ed representative
representative