HomeMy WebLinkAboutDisabilty_Whitten"", APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
.� ,
Smla Fam 43710 (R919-OB)
Prasm'bed by Ihe DepaNmenl d Lool Gme�mienl Frunce
Information eontained in Ihis doaiment is CONFIDENTIAL pursuaN W IC 6-1.1-12-12(b).
CWNTY TOWNSHIP YEAR
Fi
INS7RUCTIONS:
To be fi/ed in person w by mail with fhe CountyAudita o/the wunty where the property is bcated.
FN}g Da(es: iJ Real Properly: D�xirg Ne year fa whirh lhe ded�ctan is saght.
2) Mobile Homes assessed uMer IC 6-1. f-7 or Manufactured Hames nof assessed as Rea/ Pioper(y:
March 31 W each year fhe individual wishes to obtein fhe deduc8p�. �
See reverse side7oraddifional insWdions aMOUalificafims f:�on..'�
Is epp�iom
M No, xtut is hisrher axap
�es ❑ No I
H ruma m retard'a AilfareM than ttul d appfwanl iMicale balrnr.
Nama d coMrarl se�ar
ACdress d mntratl saAer (mmDer antl sbeol �Y, sbfa. and ZIP mtle)
L5 applicaN dind as deWed in IC 12-7.2-21(1n
❑ Yes
� Na v�m �a a„a o�,vrea o�ar
❑ No
ii4ha.resdence?
❑ No
Keynumber/Legald
/Y � I�l /Y �
�AN 3 2013
D�{nrg the tweNe (12) montlrs 6e/ae
of'vrte�e519 tl awned with mmeme aftrer Ihan spousa,
rt�dimle with whonc
Is �he vooaM in qua9im:
❑ ��v ❑ n„r�,anva�s�ea
Mo6de Fiane (IC 61.
Is applimN disabled aM unaMe b a�gage'v� arry wbstaNial gai�dul atlivi
as defined in IC 61.1-12-11(A)?
Yes ❑ No
Does ihe avd�m's la�mda gtoss incoma (w Na P�eceErtg calaMar year
esraeE 517.0001 '
❑ Yes ❑ No
� aaae riumber
INVe certify under penalty of perjury thaf lhe above and foregoing information is W e and wrrecf and fhat [he applicant was a resident
of Indiana and owner of the aforementioned property on March 7. 20
(rnmber md street. cily, sYate. and ZIP m0o)
aufhor¢etl reprasentative (number and strec(, cify, 5!(e. arW