Disabilty_WhittenY'�`-� o� APPLICATION FOR BLINO OR DISABLED PERSON'S
l. �- y, DEDUCTION FROM ASSESSED VALUATION
Slaie Form 41770 (R7l 5-06)
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PresoibtN bY �e Depariment of Loral Goverrvneni Fu�a�¢
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ntamation contained in this document is CONFIDENTIAL pursuant ro IC 12-1-7-7(n) and IC 6-7.1-12-12(b)- File Mark
INSTRUCTIONS: �� ��
To be �led in person or by mail with the County Audilo� of the county where the property is locafed.c;
Filing Dates: 7) Real Property: During the 12 months before June 17 0! the year the deduction is to bE�����e0UN7Y qUDITOR
2J Mobile Homes assessed under IC 6-1.7 J: Ouring Ihe 72 months belo�e March 2 oI each year the individual wishes to
o6tain the deduction. „ ,
See
of appGc�y[ (owner oi wnVacf
applicant the sole I��i or equitable ovmer7
❑ Yes ❑ No
name on record is different than that of applicant,
ame of wotrad seller
ddress of conVact seller
applicant blind as defined in IC 12-t-7-1(n) antl I�
❑ Yes L�bdo
� used and occupied primarily for his/her
s ❑ No
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exact share of
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If ovmed with someone
indiwte wiih whom
Is the property in quesuon:
Spouse,
�'�eal Property ❑ Mot�le Home (IC 6-1. t-7)
Is applicant disabled and unable to e�gage in any substantiai gainful activity
as defined in IC 6-7.1-12-11(d)?
�s ❑ No
Does the applicanfs taxable gross income for e preceding catendar year
exceed 577,000?
❑ Yes �lo
_ .. . �
._ ..
Pagenumber
I/We certiry under peoalty of perjury that the above and foregoing information is true and covect and thal the applicant was a�resident
of Indiana and owner of the aforementioned property on March 7, 20 _ -
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ot authorized
Addr�so(appGcant ! 1 �� _ / IAddressofauthorizedrepresenia6ve
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