HomeMy WebLinkAboutDisabilty_Livermore�� APPLICATION FOR BLIND OR DISABLED PERSON'S
_. i DEDUCTION FROM ASSESSED VALUATION
' � Siate Fortn d3710 (R7 / 5-06)
� Preso�b�,d bY �e Depanment d lofal Gwerrvnenl Finance
�Infortnation contained in this documeni is CONFIDENTIAL pursuant to IC 72-1-1-1(n) and IC 6-1.7-12-
NSTRUCTIONS:
To be (led in person o� by mail wilh the Counly Audiior o! the counfy where lhe p�operty is
Filing Dales: 7) Real Property: Dunng the 12 months 6efore June 17 of the year the deduction is to 6�j �e ive.
2) Mobile Homes assessed under IC 6-7. 7-7: During the 72 mon(hs belore March 2 ol�MCh �aG�tF�Bividual wishes to
• obtain the deduction.
See reverse side for additional inslructions and
Name o( applicant (owner or conVact buyerJ
�IJ�b ol..
is applicant the sole legal o equiWble ovmer?
❑ Yes � No
If name on record is diflerent ihan thal of appiiwnt, ii
appGcant biind as defined in
❑ Yes I�QIo
property used and occupied primarily (or his/her
❑ No
No, what is his/her exact share
1.1-12-12(b)? Is a�
as d
�esidence7 Doe
exct
:y number / Legal description
GIBSON
If owned with someone
indicate with whom
Is the property in question:
spouse,
�❑ Real PropeAy ❑ Moble Fbme (IC 61.1-7)
t disabled and unable to engage in any wbstantlal gainful activity
in IC 6-1.1-12-t�(d)?
ihe applicant's
�tl $17,000?
_��IS- I�o-t�/• 535'
gross income fa
Record number
�'es ❑ No
the preceding calendar year
❑ Yes
IM/e certify under penalty of perjury lhat 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 _
of applicant
�, ( -
�
iwre of authorized representative
24%7 E Gu4tt%r l.A� I'�r^'tF lati, 47G f0
represenWtive
� �