Disabilty_Cropper'°" APPLICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSNIP veart
, DEDUCTION FROM ASSESSED VALUATION
� , State Fortn 43710 (RS / 6-03)
Prescribed b the Department of Local Govemment Finance
Y � T ';�r T�i—^J �
infortnation contained in Nis document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12;�-2(b).� �3 " � j
i�UCT10NS: � Il /
e filed in person or 6y mail with the Counry Auditor o/ the county where the property is locatedr ; r� 'n �3
Filing Dates: 1) Real Property: During the 12 months before May 11 0! the year the deduction i s i�o be elfesti d b!
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 0/ each ye�a[r the
obtain the deduction. �j � � y�
of applicant (owner Qr cont2ct
sole Iegai or equitable owneY.�
name on
Name
Address of contract
p�/€s ❑ No I
an that ot applicant, indicate below
app�iwnt blind as defined in IC 12-7-1-
❑ Yes
Ne property used and occupied primar
❑ No
diSVitt
with someone
vrith whom
�1 — Is the prope i
i \J
eal Rope
Is applirant disabled and unable to engage
as de�ined in IC 6-7.1-12(d)?
Does the applicanYs
exceed $77,000?
number I Legal description
gross
wishes to
spouse,
y❑ Mobile Home QC 61.1-7)
i any subs ' I gainful activity
s ❑ No
r the preceding calendar year
❑ Yes �?f6
Page number
IIVJe certify under penalty of berjury that the above and foregoing infortnation is true and correct and that the applicant was a resident
�'ndiana and owner of the aforementioned property on March 1, 20 _
�
representative
