Disabilty_StricklandAPPLICATIOPI FOR BLIND OR DISABLED PERSON'S
>--- . DEDUCTION FROM ASSESSED VALUATION
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S'W � Pr�ed by thc Oepartment a Lxal Govsnment Finmwe
Intortnation contai�d in fhis documem is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).
INSTRUCTfONS:
COUNTY TONMSHIP YEAR
�I
Fle Mark
NOV 2 p p012
To be fi7ed in person or 6y mai7 wifh the CounlyAuditw d the county whe�e the p/oper(y is (ocated. C. �.
Fding Qates: 1J Real Properry: Dunrg the year lor which the deduCion is sought
2) MobJe Homes assassed under IC b1.1-7 or Manufactured Homes nW assessad as Rea! RopertrC�hranv the lu27ve 2) onths before
March 31 o/each yeartl�e individual wishes to o6tain the deduction. '"'°viV CO�NTY q�plT p
See 2varse side for additional instruclions and qualifirations.
Mame of ePW��� (owner oranaaa buysd
is ePP�t the sde legal n e9 ame(? If No. what is hiM�er exact shere interast? Ii ovrt�ed wiM someone other than spouve.
hitlirate wkh vAern:
tt name on rernttl
I: n�'
Yes ❑ Na
aan aiat W applmnt mairafe be�ow:
AECress oi cantract seilef (rtumberarM straet dry, state,
�s 2PP�t bOM az deCmed in Ic
Yes L! No
h 1he pivperty ux0 md ocaP�d P�Y for ldsmx residerroe?
❑Yes ❑No
IT,r,.7.irsl
��acir.!� ;-;�
1s me propelry in wgua�:
C� r� aav�r � a�nvw�a
r,�tle t�n,e pc ��
Is aPP�t dsa6letl aM una0le to enga8e b�Y �� 4� �Y
25 defi(180 in IC 61.1-12-17(CI?
�Yes ❑ No
Doee t1a a rs ta�ede grox i�ane fcr the
exceetl 57 .�07
❑ Yes
Recad nurtiber � Pege rnenber
V4l�p€rtify under penalty of perjury thai tF�e above and toregoing infortnation is Vue and correct and that the applicant was a resident
of Indiana and owner of the aforemenGoned propeRy on March 1, 20 _
� � avaa�n
�
ntlCress a avw��m t�ae. end meet �r. sate, and Zla oade)
� ewnROe r6�re�ntatire � nddress w eunwr'¢nd represenmMe (m�maerard aneet �r smea� em z/a code)