Disabilty_Delaney- APPLtCAT10N FOR BLIND OR DISABLED PERSON'S couem' row+rvsx� r�ue
•• DEDUCTION FROM ASSESSED VALUATION
sate r�„ aa�io tas r sos�
"' w+ � Presa�ed �, u,e oepnmme�n w Lxa� co.mment Fi�ance
Informatlon contained in Mis document is CONFIDENT7AL pursuant to IC 61.5-12-� 2(b). e
INSTRUCTlONS:
�mear���abymee�nn�c«�„tyn»aaaame�u„ry��ma�Pe,ry�a�red. SEP 21 2012
Aates.� 1J Real Property: During Me yrearlor wh�h Ne deducfnon is wughi
2) MobJe Homas assessed underlC b1.1-7 w ManutaGUred Homes rwt assessed as Real Properry��ruig�Ne, (!2J months 6efora
A4am.li 31 of each year the individual wishes to obtain the dedudion. v
Sea reverse side foradQllional insfrtictions and aualihcations. .. �.,�,.., ,.,.. �.�r., . ,...
Name ot apptiant (otmeror contrsd buyerJ
�
/U.� ��
If Na. wha[ is ' exea share of inte�ast?
U Yes u No �
tt nama on'emrtf Ls tlAfetetrt Nan ihat d app&ant htlkate Cebw
`�QQ s, C��.o.L l� ti¢�C'1��+�-�,
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AdGress ot tanVad se�ler (number aM sfreet �Y state, an0 LP ootle)
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�s ��c nc�w � mrmec m ic iza-s.zi�i�z
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If owned wtlh someone other tlian sCa+�.
'u�dicate arth wF�un:
: properry in w�n:
� ��v � �Y�
n�i� r�n,e pc �i:
is �m d�a ana � m e�yaye m anr wosw++� saww a�nv
as defitretl M IC frt.t-12-17(Cit
❑Yes ❑No ❑Yes ❑No
h uro a�overtr ueed m�a oxupied primanb ror niall,ar reside�we? ooea aie apqicante taxab�a gmb income tor nre preaedmg cabtMar year
excced 577.�007
❑ Yes ❑ No ❑ Yes ❑ No
distrl�l Key num6er! Legai des�i�lian Remrtl numha Page nwnber
��-/�-(�%�3-DU/.�3 D��
t/We certify under penalty oi perjury that the above and foregoing infortnation is We and corred and that the applicant was a resident
of Indiana and owner of the aforementianed property on March t, 20 _
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representative (number aM sneet �+N smte. eM LPCOde)