Disabilty_Doerner' ""' APPLICATION FOR BLIND OR DISABLED PERSON'S
. � DEDUCTION FROM ASSESSED VALUATION
State fpm 43710 (R919-OB)
'+ r
PrewibeE Oy Iha Oeparlme�n d Lod Grnemrnenl Finance
Infwmatbn wntaineC in this document is CONFIDENTIAL pursuant [o IC 6-1.1-12-12(b).
INS7RUCTIONS:
COUNTY TOWNSHIP YEAR
File Mark
DEC 5 2012
To be fi/etl in person w by mail with the CountyAuditor o/ fhe county wfiere fhe propery is lacated.
Fdug Dates: 1 J Real Properly: Ounrg the yeai (a which fhe dedudion is sought. C. �. �
2) AbW7e Hortres assessed under IC 67.7-7 a ManufaUured Homes nd assessed as Real Ploperty: During the lweNe tl�s 6elde
March 31 0/ each year the individuel wishes to obtain the deduction, n�ocnu nn� �.�t.. .��..
See reverse side faredddional insWCtions andQualificafions —'��•••• •••,••�• ��••••••� � v•
Narre d aPPfi�N (m.nor v wnhact
Is aPP6rdm Ihe sde lega ec �lade R H No. what b his�her exad share N interesCt 7 owned with mrreane aher Uian sVa+sa,
indmte with wfio�re
❑Yes ❑No
tl rwne m recatl a OiEaranl tlian Nal d appfranl iMrata bebu-
Nama W cantrad se0er
Address d wntratl seGar (mmDei ad stred. cilY. smfc. anC ZIP oode) �Is M�/e P�WBNY in Queslian'
� / - � ��Y ❑ Mot7de � 1.1-7)
Ls appl�m bGnC as CeEneE in IC 12-7-2-27171? ts appl'vetl dLSaOled anC �naMe b engapa in a�ry wbstaNial g2i`AUl atiivily
� e�r�d � �c s-i.�-i2-�i�e�a
❑ Yes No � ❑ Yes ❑ No
�s me a�weM �sea a,e ocwa�ea o�mar�r ror nNner resde�ra? ooes ure aad�m's ta,ada gross income rw tna v�e�eaH9 aenaar year
eswed 57�,0007 "
Yes ❑ No ❑ Yes ❑ No
Tasirg Eistrict Key number I Legal desaipl' Recortl number Page number
� � _ aoo D�-o 6
I/We certity under penaity of perjury thaf the above and foregoing information is lrue and correcl and that the applicant was a residen�
of Indiana and owner o( the aforementioned property on Maroh 7. 20 �
�Signatura d appSmN Pddress ol applimM (rw•rNrr and sbeef. aty, sfafe, antl ZIP wtle)
B � �Jof�-- � 6 , l f> ,� �1/�',� 6 �
natu auUronzeG reprrsenlative Aeeress of authorized rapesentative (numDer aMsveef, city, state, antl LPcoOO)