HomeMy WebLinkAboutDisabilty_Wells (2)"'"o APPLICATION FOR BLIND OR DISABLED PERSON'S �o�Nn' '
�i, -..- 5 DEDUCTION FROM ASSESSED VALUATION
'� State Form a3770 (Ra I 70-0t) �.
5�::"� Presrnbetl by the Department of Local Government Finance �
��`" �nation contained in this document is CONFIDENTIAL pursuant [o IC 12-1-1-1(n) and IC 2�2(�
RUCTIONS: u
To be filed in person or by mail wifh the CountyAuditor olthe counry wheie the p i3Tocated.
Filing Dates: f) Real Property: Dunng the 12 months befo2 May 11 of the�ear the deduc�q�Q�js tq f� �jve.
2) Mobile Nomes assessedLnder IC 6-1.1-7: Behveen Janua 15 and MarcA .`�� �of the e� r the d/
See reverse side fo� additional insfructions and qualifications. /' /'�!�'� /,
1/ `--� -i.U-�t5
Nameofapplipnt(ownerorcrontractbuyer) , _.,,,,,,,,rnntTYFU017
� � Q
Is applicant the soie egal or eq itab owner? If No, what
❑ Yes ❑ No
if name on record is diBerent than that of applicant, indirate beli
contract
applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.7-72-7
❑Yes ❑No
property used and occupied primarily for hisRier residence?
❑ Yes ❑ No
district
number
TOWNSHIP I YEAR
file Mark
is to 6e eflective.
share of interest? If owned with someone o[her than spouse,
indicate with whom
Is the property in
� ❑ Real Property ❑ I
Is applicant disabled and unable to engage in any s�
as defined in IC E7.7-12(d)?
Yes
Dces the applicanfs taxable gross income for the pn
exceed 517,000?
❑ Ye5
Home QC fr1.1-�
❑ No
I/We certify under penalry of peljury 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 �� � n w Signature of authorized representative
t
representative