Disabilty_Flusche `716:;t, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
ikb E �_ DEDUCTION FROM ASSESSED VALUATION
'° State Fam 43710(R9/9-08)
Prescribed by the Department of Local Government Finance . ____________
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). e M.1 U .p,
INSTRUCTIONS:
To be filed in person or by mall with the County Auditor of the county where the property is boated. APR 3 0 2014
Filing Dates: 1) Real Property: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 Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction. n
See reverse side for additional instructions and qualifications. 7�."'t`^hIM(
Name dappacant(,1. .
y. or contract boyar) � � Gi8501V LOUIVIY AUUIIUK
Is eppecant the sole -/ eq i owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
es ❑No
If name on record is di(faent than that of eoyB-ant,indicate below.
Name of contract seller
Address of contract setter(number and street dry,state,and ZIP code) Is the property in question:
0 Re Prey ❑ Annually Assessed
Mode Home(IC 6-1.1-7)
Is applicant band 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 El yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
El Yes ❑No El Yes ❑No
Taxing district Key number I Legal description Record number Page number
c9(0 -012-59-03(2-600- 300-0 9
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 apprwant Address of applicant (number and street city,state,and ZIP code)
�'�� ,,Ss 0 7 a -H ucci d LoG yo
Signature of representative of authored represent Live (number and suee4 c/1: ZIPcode)