Disabilty_Cummins�
� ""' APPLICATION FOR BLIND OR DISABLED PERSON'S
. . DEDUCTION FROM ASSESSED VALUATION
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S�ab Form a3770 (R9 / 4-08)
PresaiCeC by ihe DeparirtreM d Lo�al Gaemmenl Finance
Informatiom m�tainetl in Ihis tlocumen� is CONFlDENTIAL pursuaN to IC 6-1.1-12-12(b).
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INSTRUCTIONS: 1,� qp
To be filed in person or 6y mai! wiUr Ihe Co�rrtyAuddor o/the counry rt+eie tl�e properiy is bcated. IY�V Li �7 �� � 2
Fifilg Dafes: iJ Real Property Ounrg the year la whicA the deduction is soughL ,,..nn--..��--
2i Mobde Homes assessed uMer IC &7.7-7 0� Manulactured Homes nU assessed as Real Rope�iy: Duriwg fa�f2�'pronfis 6efae
Mamh 31 W each year flre individuel wishes to obfain the deducfion. ��
See reverse side lmadditbnal insWdions arM qualifications ITOR
Nama o( aPO�i�M�(ywncr m cmtracl Auled
Is appfimr� Ihe sde iegal ar epuiWble owneY? I M No, wlul is harher ezaG
U❑Yes ❑Na
H nama m recnd is diflareni Ihan Nal d appfiranl iMirate balrnr.
Name d mntrad 5e0ar
nedrass d�iaa �oar ��aw ar,a wew. mr. �m. a,d zra ��
Ls appliranl btiM az definetl in IC 72-]-2-21�1/f
6 Lhe propeM � anE
Yes LJ No
❑ Yes ❑ No
Key numDer / Legal Eesoip�ian
wiln wmeane
wilh wtwm
r v�nr � m���
ReaIR'operty � Mrn�aByPSSessed
Mohde Florne (IC 61.1
Is applit2nt disabled aM unaMe lo erc�age in ary suhstaNial gain(ul activily
a defineE in IC 61.142-01(d�?
Does u�a
azwed 5
Yes Lf No
xd'mg ulandar yrar
❑ Yes ❑ No
RemN number Page numGer
IIVJe certify under penalty of perjury thal the above and foregoing information is true and correcl and thal the appiicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature of appGwL/`/'"Y"
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SgnaNre W aulhar¢ed rapresentative
Address of applimnl (rvmber aM sbed. ury, sfalc. aM LP mde)
C aoi6 .voc�� P�rcRsB�r�� R�4. P.�.�I,v_ Y��
AdErass of aulhorized representative (numDC� aM suee( ciry, statc, and Z!P co0e)