Disabilty_Davis (2) APPLICATION FOR BLIND OR DISABLED PERSON'S lx� 1- •2s ilir _ YEAR
1: DEDUCTION FROM ASSESSED VALUATION
;�!.!�<- Stale Form
by ep/9-0a) ��p
Stale Ford by the Department of Local Government Finance rt'
0 Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). Q C tll f`'�''L u hi
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county Where the property is located. 711
Filing Dates: 1) Real Property:During the year for which the deduction is sought. d'"r / j/"�
2) Mobile Homes assessed under IC 6-I.1-7 or Manufactured Homes not assessed as Real Proptitteq ;(121.months before
March 31 of each year the individual wishes to obtain the deduction. "'—""� AAAAUUUUDITOF
See reverse side for additional instructions and qualifications.
Name &o7d9J wner or contract buyer)
` 40 <.Is applicant the sole legal or eq eR It No,what is his/her exact share of interest? If owned with soneona other Than spouse,
,��,,���.,...///// indicate with whom
Yes ❑No
If name on record is different than I of applicant indicate below:
5o UtAlti74,i0 ii- kO
Name of contract seller
Address of contract seller(number and street 04..state,and ZIP code) Is popery in question:
Real Property ❑ Annually Assessed
Mobile Borne(IC 6-1.1-7)
Is applicant blind 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 ❑No Yes ❑No
Is the property used and occupied primarily for hiss er residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
oyes ❑No ❑Yes )No
trict Kay number/Legal desaipliolL� Record number Page number
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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 �p \ / Agage ddrdressof appplicant/-r/(, nbe,and street,city, fate,and ZIP code) 54i,
7( i/ 0 5) G'*-,�-+ CN• /A' - '2 a M&Q
Signature dre of a representative Address of authorized representative (number and sheet ty state,and ZIP code)
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