Disabilty_Martin"" APPLICATION FOR BLIND OR DISABLED PERSON'S
. - : DEDUCTION FROM ASSESSED VALUATION
.. Stala Fortn 43710 (R9 / 9-OB)
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��• PreStribad bY Me DaPah�� d Loml Gm�ammenl Fi�axe
Information oontained in ihis document is CONFIDENTIAL pursuanl lo IC 6-1.1-12-12(b).
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INSTRUCTIONS:
To be fited in persan w by mail �xth the CountyAudRw o/ fhe oounty where the properly is bcafetl.
Fdiry Dates: 1J Real Pioperty: Dunrg the year /or whih the deauction is soughl.
2) MobiJe Nanes assessed under IC Gf. f-7 or Manu/actured Homes nof assessed as Real Pio��"� th�(7 rtwnths be7ae
Ma�ch 37 0/ each year Me iMivi�ual wishes fo o6tain fhe deducfion. �' A DITOR
See reverse slde Ior atlddional insWctions and quafifications.
NarreafzVMwarE( arcanfrdcfdiWO � �
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I5 appGaea the sde Iegai or epuilade wmaR @ No. 1 haR�er exad 5hare N'vrteresY? B owned with songu�e alher Ihan 5poum.
indimte wilh w'hom:
❑ Yes ❑ No
tl reme m remrd is C�areM than Ihat d appfimnt iMicate Oelwr. '
Nameo(canlraU r
P4drass of tra seGer (rvanbw aitl strvc+. ary. ffih't. antl Z/P mde) 6 Na properry in questiort
❑ ReaIR'opertr ❑ nnrn,aovwssessm
lAOhtle Fiarne (IC 61.1-n
6 appfimM bfiM az tlaEneE in 1C 12-]-2-2111/! Ls appimM EiubleA aM unade to a'gage in arry sudslaN"vl gaiMul aCivrty
as defi`red in IC 61.14241(C�?
❑ Yes o Yes ❑ No
Ls Ne P�weM useA and «cuPaE PM�M' fw �isThar resEence? Ooes Ure aVd�nTs �axade gfnss'u�c«na fw Ihe P�ecedm9 �lendar y�r
� exreeE 577.00V1 '
Yes ❑ No ❑ Yes o
Tazi(g distiict Key number I Lepal desaiption Recortl number Page number
�� -,7 30-f e0_f.�l_�bq-� �
I/We certify unde enalty of pe � Ihal the above and foregoing information is We and wrrect and that the applicanl was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
Signatura o( appGmm Address ot appticaM (wmber and streW. ary, sra�, antl ZIP mde)
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SignaWreolaulhmzeArapresema e ACtlressotauthorizeEraprasentaliva (numDeraMslrocl.cky.state.andLPCOde)
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