HomeMy WebLinkAboutDisabilty_Robinson (2) .: , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
E' DEDUCTION FROM ASSESSED VALUATION
.' State Farm 43710(ft919-OS)•
Prescribed by the Deparhnent of Local Government Finance
L _- _.
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: APR 1 a 2013
To be bled in person or by mad with the County Auditor of the county whets the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought I', q!1►11.i:
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Pro ;r)pr{ o i •.ay: ` mots before
March 31 of each year the individual wishes to obtain the deduction. ,1 TeiR
See reverse side for additional instructions and qualifications.
Nama�t(owrreror contract buyer) � eze:pcs1,x_)Is appli cant the solo legalc er? at is hillier exact terest? If owned with someone other than space,
indicate with vAtan:
Dyes 0 N
If name on record is different than that of amt.:ti 4 Indicate below /
`eda-A � Al ri � 0/�v
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) `Is property in question:
Real Property 0 AnnuallyAssessed
TT" Mobile Fame(IC 6-11-7)
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 defured in IC 6-1.1-12-11(d)?
❑YesNo ❑Yes 'No
Is the property used and occupied primarily for histher residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17.000?
NIX/Yes ❑No ❑Yes No
7;0
Key number/Legal descliptian Record number Page number
jP--ice aJCO—tCM 9/5
UWe certify 'er pena f perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner o e aforementioned property on March 1,20 .
XSignature of applicant Q Address of applicant (number and street,city,state,and ZIP code)
/'.•�CIG /�/� ce-!//U� � X-7 / 9 S .s 5�G 0 Grp ocAdE2.5(i/1Li Zti �7�CS
Signature of nz�d representative Address of authorized representative (number end s9ee4 ay,,slate,and ZIP code)