HomeMy WebLinkAboutDisabilty_Tolbert""°'°4 APPLICATION FOF�"8�L3 OR DISABLED PERSON'S courm TOWNSHIP YEAR
3�!� �. ,, � DEDUCTION FRONf ASSESSED VALUATION
`\-�?� Sute Fortn 43710 (R / 9-96)
��' ,`°• Prescnbetl Dy ihe State Board of Taz Commissioners -
nrormation coNained in this documeni is CONFIDENTIAL pursuam ro IC 12-1-7-1(n) and IC 6-1. -7�2-72�b . � File Mark
INSTRUCTIONS FOR FILING: ���, ry j[��
To be filed in person o,-by mail with the CountyAuditor of the county where the propeNy is c ,._G��,(
ted during the 72 months be%re May U o/ the year the deduction is to be eflective. d�
See reverse side lor additional instructions and qualilications. � uii Q� 2000
Name of ap : (owner or contract buye� � �
, pQ�, ^ :�,-� �s�. .�Q. ,D
,� ,.�«...
I5 appiicant the s e legal or equitable owner? If No, what is hisfier exact share of interest? ��� Ifowned wi[ksortieone other than spouse,
indicate with whom
Yes ❑ No
If name on record is ditterent ihan that of applicant, indicate below
Name of contract eller
W
Address of contr ct seller
Is applicant blind as defined in IC 12-t-1-1(n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any su ntiai gaintul activity
as defined in IC E7.7-12(d)? es ❑ No
es ❑ No
Is ihe property used and occupied prim rily tor his/her residence? Does the appliranYs tauable gross income for Ihe preceding calendar year
exceed $77.000?
i
� es ❑ No ❑ Yes ��
Taxing distri Key number / Legal description Record number Page number
�' ab��3 d a
I/We certify unde nalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the a(orementioned property on March 1, 19 �
� nature of applicant Signature of authorized representative (by executed Power olAttomeyJ
� �. ��..��� _
Ad ss of applicant Address of authorized representative
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