Disabilty_Hacker ±r• .r, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
6 DEDUCTION FROM ASSESSED VALUATION
.' State Fenn 43710(R9/9-08)
Prescribed by the Department of Loral Government Finance
.In : la :a..
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). -'P�' t
.
INSTRUCTIONS:
To be filed in person or by mall with the County Audrtor of the county where the property is located. JUL 2'2`2013
Filing Dates: 1) Real Property.Owing the year for which the deduction is sought
2) Mobile Homes assessed under lC 6-1.1.7 w ManufaCUred Homes not assessed as Reaf Properly.During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and quafihcatiohs. OtB30N COUNTR
Name of applicant(on erw buyer)
is applicant the sole legal or 0 No,what is higher exact share of interest? If owned with someone other than spouse,
indicate with vtan:
2les El No
If name on mooed is different than that of applicant.Indicate below
Name of contract seller
Address of contract seller(number and street,cM state,and ZIP code) Is the property in question:
-❑ Rem Property ❑ Annually Assessed
Mot&Home(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 activity
as defined In IC 6-1.1-12-11(d)?
❑Yes 0 N es 0 N
Is the property used end occupied primarily for Ns her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17000? ,�
El Yes ❑ ,__
No ❑Yes No
Taxbig dlsbi Key number I Legal description Record number Page number
a6 - ►i-13-aoa-Do t. 99 8 /
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 soee4 city;slate,and/ZIP a#e) n
X 3��/� (:Q3 R $ Po ? 1v- 4 /s Or Y'ri nC42 c TJ�/