Disabilty_Egbert E+ {, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY >�IP YEAR
r „ DEDUCTION FROM ASSESSED VALUATION $
- state Form 43710 R9/9-08) II
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). NOV 1 2 2013 le Mark
INSTRUCTIONS:
b be filed in person or by mall with the County Auditor of the county where the property is located.
Filing Oates: 1) Real Property.Owing the year for which the deduction is sought ' ��.jrtrlfir
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as mgt -,i,••,:k*a+t7... • . . v. ■ -•)months before
March 31 of each year the individual wishes to obtain the deduction. G 16
See reverse side for additional instructors and qualifications
Name of appllnnt(0 rat anfract buyer) ^
V
Is apparent the sole legal or equitable e(? If No,what interest? If owned.with someone other than spouse,
indicate with Warn:
Dyes ❑No
If name on record Is different than that of applicant indicate below.
Name of contract seller
Address of contract seller(number and street,drg state,and ZIP code) Is the property in question:
Property ❑ AnnuallyAssessed
I
Mode Home(IC 6.1.1-7)
Is applicant bend as defined in IC 12-7-2.21(1)? Is defined bdlsabblled.1aten2-N�e to engage hi any substantial gainful activity
El Yes 0 N 1 es 0 N
h the property used and occupied primenly for hisaar residence? Does the applicant's to able gross inmrire for the ing calendar year
exceed$17,000?
❑Yes El No El yes pNo
Tatngg ° ,�/ Key number I Legal description Record number age number
PalleVniel 0? 11—/F/Oa-coo goa Co h
I/We certify under penalty 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
I
Signature of applicant Address of applicant (number and street,ray,stale,and ZIP code)
5--- 7'ce-e-741— 10 I I w? (-4- Me 2 /
Siam-II:tie=representative Address of authorized representative (number and street,dry,state,and ZIP code)