HomeMy WebLinkAboutDisabilty_Quinlin Jr E r {, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY liTOWNSHIP YEAR
• t `�� DEDUCTION FROM ASSESSED VALUATION
State Form 43710(8919-08) F LE
���// Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: L 2 6 2013
To be flied in person or by mall with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:Owing the year for which the deduction is sought
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Profs t kq 2)months behue
March 31 of each year the individual wishes to obtain the deduction. UNTY A UDITOR
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)SIs appf��the sole legal or equitable owner? If No,what is his her exact sham of interest? If owned with someone other than spouse.
•
-, indicate with Wan:
tel Yes ❑No
It name on record Is different than that of applicant,Indicate below.
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) the In quesbac
Property Annually Assessed
Motae Home(IC 6-11-7)
Is applicant brow as defined in IC 12-7-2.21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
((((_..� as dented in IC 6-1.1-12-11(d)?
CD Yes
o 'es ❑No
Is the property used end occupied primarily for residence? Does the applicants taxable gross income for the preceding calendar year
exceed 517,0007
t-m NO El Yes ❑No
Taxing district Key number/Legal desatptan 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 Address of applicant (number and street city,state,and ZIP code)
�k�[p =� J ,Qi \(p 9�r s 4-4ins 54r tt P t„«fdn let) '1747°
ahgramue of authorized representative Adticess of authorized representative (number and street uh,state,and ZIP code)