Disabilty_York err t. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
� �� DEDUCTION FROM ASSESSED VALUATION _ _
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Prescribed by the Depamnent of Loral Government Finance
RINI
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). ; Fil :
INSTRUCTIONS:
b be filed in person or by mall with the County Auditor of the county where the property is located. MAY 0 5 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 Pmpprty:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse additional and qualifications. /^/
❑Yes [ No
If aware on recant is different than that of
Name of mrmaa seller I
--1-1 c--
Address of contract seller(number and street city,state,and ZIP code) Is the property in question:
tnl ro
}� Y ❑ AnnuallyAssessed 1.1-7)
is apogean!blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable tooeengage in any substantial gainful affray
as defined in IC 6-1.1-12-11(d)?
❑Yes ( ‘ii gtYes ❑No
Is the property used end occupied primarily for hislher residence? Does the applicant's taxable gross income for the ping calendar year
exceed$17,000?
S es ❑No ❑Yes Nelo
�
',i` Key number/Legal desaipdon Record number Page number
l�Ce a&-101-67-aoi-00/.773-0a8
UWe 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,slate,and ZIP code)
\1%ei/,,1. —e4 C '' k) 4776 /-5 O,
Signature of authorized Address of authorized representative (number and street,city,state,and ZIP code)
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