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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
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Pr�a�bed by ihe DepsNrent of Laal Crnarurent F�mice
Infirmation contained in tlris document is CONFIDENTIAL pursuant to IC E1.1-12-12@).
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INSTRUCTIONS:
b r� roea;� ce,� a ny �v �,tn a� c«„rrya�erro, a me ca.�ty �� r�B wovertr � r�rea. FEB T`� 2013
Fding Qates.• 1) Real PropeRy: Durirg Me year tor which Me dedudion is sotght
2) MobJa Homas assessed underlC Gf.1J w Manulacturad Homes not assessed as Rea! Property: Du ' theuhsr s before
AQatch 31 W each year the indivrdual wislies to obtarn N�e deduclion.
See 2verse side kuadditional instruGions and qualificatiaw. UNr( AUDITOR
Name of appiant (mmeror buyed
Ls epP�t the sde legal or ameY�/ If No, what is halher exea share of interest? i( o�med with somewie otfrer Itan spou�e.
6�dirate vrith W�an:
js ❑ No �
rc re�e on rec«o rs amerem m�, a� a apq� a,e�e nemw
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A6Gress oi contraU seller (numberarM streat dN, state, ar�0 LP �
6fuW as defineG in IC 12-7-2•21(7)?
Yes LI No
h� tlx P�PaM1Y uxd eM occupiad P��7Y for hq/har residanca?
❑ Yes ❑ No
Tari,p d�strid Key nwnGer
1s me prope(ry in w�ron:
❑ ��P�Y � ��Y�
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Is app�ant QSaWetl aM unahle m engage N any suGstantW adrvGy
az tleNreC In IC 61.1-72-11(ar7
es ❑ No
Doee the aoofi�anYa ta�ble 9�+ inmrtia for the Meoed�m9 �ebrMar Year
exoeed S1Y 000T ,�, �
❑ Yes lf1Ko
tlesuiptlon Recad mimbel Pape n�snber
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UWe certify under penalty oi perjury that the above and toregoing infortnalion is We and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20 _
ET'y':C_"
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Atl�ess of appkam (�mrbe. end af+uet, dll: sbte� antl21P mme)
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