HomeMy WebLinkAboutDisabilty_Kunkel_ "' APPLICATION FOR BLIND OR DISABLED PERSON'S c a rena
' . - - DEDUCTION FROM ASSESSED VALUATION '
� Smb Fortn 43710 (R9 / 9-08)
.' v
are:.rsibed oy me oeoaenre�� d �ora� Go.erruriem F�rcs
�nformation confained in this document is CONFIDENTIAL pursuant [o IC 6-1.1-12-12(b). �AN �d� A�2
lNSTRUCT70NS:
� To be filed in C.�. M°$�"-\
persan w by mail with the Countyqudifw o7the crounty where the poperly is bcate�. i�
Filirn� Dates: 1 J Real PropeAy: Dunrg Ne yeai /cv wh�ch Ne deduction is sought V v
2) Mobile Hpnes assessed uMer IC 61.1-7 w Manufacturetl Homes nW assessed as Real Pro�{qr��(t�vqy�yJ ypg�rs befae
March 31 d each year the indivitlual wishes to obfain the deductian. .
See reverse side for addnional insWCtions antl aualifications
Nartreo(ap rtl(owrvrorconfrac(buycl�
�s a��Kam ir� wie �egai w ea�aade ownen tt r+o. � a n�m�. e�a snare or �m�n if wmetl wilh somBOrie dher Uun spouse,
md�mie w�tn wnom:
❑ Yes ❑ No
tl�me on rxad is d'AfareM Ihan Cat d appfimnt iMrcate babw^
Nartie d cantrad se0er
Addrass d mntratl m0er (munberand sbeeL �: sFdle. ard ZIP cotle) Is Ihe
pweM in question:
❑ tzeaiPropertv � %�+�v��
Mo6ae Fiorne QC G1.1'�
Is applimn� bGnE as Ee6neG in IC 72-]-2-21(1Y! . Is appli�nl disableE and unaWe to erqage in a�ry wbstaritial gainlul aaivdy
as Eefined in IC 61.742-01(d)7
❑ Yes ❑ No ❑ Yes ❑ No
Ls Ne PmpeM used aM aruPad primanN (w hislher resideM:e? Dors ihe aPPM1��i's tuable gross income for ttie P�eraEing denGar y�r
ez�eC 517,000? '
❑Yes ❑No ❑Yes ❑No
�(icl Key nvmbet f Lagal desaiption Reron1 number Page number
�� . a(� -��-o9-ioY-noa.o38- �a.
I/VJe certify under penalty of perjury that the above and foregoing infortnation is true and cortect and that the applicant was a resident
of Indiana and owner of Ihe aforementioned property on March 1, 20
Signaturao(appficanl Addressotapplimnt (mim6riaMstree;cdy,sfa�,aibZlPmtle)
� ,' ' � �
' k I y�C� 0-r L d I��r �� `�7�7a
SynaWre daulhonzed re resentative Pddress of aNhorized represen�ive (numDer aMsLCro4 «y, sWfe, anOLPcnd:)