Disabilty_Johnson r =_Y, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
: State For,43710(R9I9.08) .
Presented by the Department of Local Go-imminent Finance
• Mili ice,
Information contained in this document is CONFIDENTIAL i i i 1 i.7- • i,3
pursuant to IC 6-1.1-12-12(b). •
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. JAN 1 3 2014
Filing Dates: 1) Real Properly:During 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 Properly: {;ring the two (12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. GIHST N COUNTY AUDITOR
Ware of applicant ,:r or contract buyer)//
Ls applicant the sole legal o • .:own Il N0.what is share of interest? If owned with someone other than spouse.
indicate with whom:
/❑Yes ❑No
If name on remit is different than that of applicant h,dkate below:
Name of contract seller
Address of contract seller(number and street cat,state,and ZIP code) Is property in question:
Real Property ❑ Annually Assessed
7 t 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 gainful activity
as defined In IC 6-1.1-12-11(d)?
❑Yes 0 N es 0 N
Is the properly used and occupied primarily for hishher residence? Does the applicant's taxable gross Income for the brocading calendar year
;Z(Yes • 517.000?
Z Yes ❑No ❑Yes ❑No
ZdistrlC l Key lumber I Legal description Record number Page matter
iaz5L1-17,40 tiG-6 /9- /f9- 32o -a/ o
IiWe certify un enalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and er of the aforementioned property on March 1,20 .
• Signature of applicant Address of applicant (number and street city,state.and ZIP code)
\\r-`L ee a30 N .�7$ Fr ,sec Tyl, . V 76 W
Signatee a1 of authorized representative (number and street miry,sate,and ZIP code)
•