HomeMy WebLinkAboutDisabilty_Perry r r,, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY To a YEAR
/ DEDUCTION FROM ASSESSED VALUATION
"Fa-K-- State Form 43710(R9 19-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). R 1 1 "19aric
INSTRUCTIONS: M Q
To be filed in person or by marl with the CountyAuditor of the county where the property Ls located. a •i
Filing Dates: 1) Real Property:During the year for which the deduction is sought ' AM P, TQR
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property. .•-, If% :�hionths before
March 31 of each year the individual wishes to obtain the deduction. G%BSON C•
See reverse side for additional instructions and qualifications.
Name of applicant( contract buyer) q o
J I n Ica
Is epptcant the sole legal or equitable owner? If No,what is hishier cy‘it stake of interest? If owned with someone other than spouse,
indicate with wham:
roYes ❑No V
If name on record Is different than of applicant,indicate below
Name of comae seller t Q
Mil Address of contract settee(number and street city,state,and ZIP code) Is the property in question
❑ Real Prey ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Is applicant band as defined in IC 12-7-2.21(1)? Is applicant disabled and unable to engage In any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes Callo ❑&A ❑No
Is the property used and occupied primarily for hisaror residence? Does the appli ants taxable gross income for the preceding calendar year
exceed$17,060?
WYes ❑No ❑Yes 'No
abli(districi Key number/Legal description Record number Page number
a \ & — 11-DS-aoa- co," Si(--o a7
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature of applicant Address of applicant (number and street Gay,slate,and ZIP code)
Signature of authorized representative Address of authorized representative (number and meet city.state,and ZIP code)