HomeMy WebLinkAboutDisabilty_Michel�'°"' APPLICATION FOR BLIND OR DISABLED PERSON'S courm TowNSHia rena
� DEDUCTION FROM ASSESSED VALUATION
�'�SWte Fortn 437101R / 9-96)
�' u, Presaibed by Ne State Baard ol Taz Commissioners
I�a6on contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.7-72-12(b). ��� ��
INSTRUCTIONS FOR FILING: �
To be liled in pe�son oi by mail with the County Auditor ol the county where the property is loca-
ted during the 12 monihs before May 11 07 the year the deduction is to be eNective. AUG � 2 1997 .
Rm roverce eirin fnr mrlllitinnnl inetn�rtinne nnrl n�mli/'rofinne
Name of applirant (owner or contracf buyerJ
GIciSUN C"OU TY AUDI70R
Is appiicant the sole legal or equit le owner? If No, what is his/her exact share of inierest?_ If owned with someone oiher than spouse.
indicate with whom '
Yes ❑ No
If narne on record is diftereni than that of appiicanL indicate below ,
Name of contrad seller
Address of contraa seller
Is appiicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-72-12(b)? Is applicant disabled and unabte to engage in any substaniial gainful activiry
as defined in IC 6-7.1-12(d)? �J Yes ❑ No
❑ Yes No
Is the properry used and occupied primarily, or his/her residence? Does the applicanYs ta�cable gross income for the preceding calendar year
ezceed $17,000?
� ❑ Yes No ❑ Yes o
Taxing district Key number / Legal descripiion Record number Page number
ao�-oo�oa_oa
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'oi the aforementioned property on March 1, 19 _
Signature of applicant Signature of authorized representative (by executed Power otAttomey)
Addreu of applicant , Address of authorized representative
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