Disabilty_Koonce ,e': ':-+, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSH YEAR
r DEDUCTION FROM ASSESSED VALUATION 1? 1 L
Et
�' Slate Fart 43710(8919-08)
' Presorted by the Deparbnent of Loral Government Finance 1�t�gfp
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). MAY (It W$
INSTRUCTIONS: '
b be filed in person or by marl with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought alleMine
2) Mobile Homes assessed under IC 8-1.1-7 or Manufactured Homes not assessed as Real Pr .�Ir�vR Garr is before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of appiicaM(owner or contact buyer,
Is applicant the sole legal or equitable owner? If No,what is his her exact share of interest? If owned with someone other than spouse,
indicate with Warn:
12-Yes ❑No
If 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) Is the property in question:
❑ RS Property ❑ AnnuallyAssessed
tulotyte Hare(IC 6-11-7)
Is applicant blind as defined in IC 12-7-2.21(1)? Is applicant disabled and unable to engage in any substantial gainful adwGy
as defined in IC 6-1.1-12-11(d)?
❑Yes 0 N ❑Yes 0 N
Is the property used end occupied primarily for NsTer residence? Does the ail �mnfs taxable gross income for the preceding cebnder year
exceed$17,0007
'LY Yes ❑No ❑Yes ❑No
Key number I Legal tlesaiptlon Rec rd number Page number
ridAtAtcern—d• c , 6 -[ l- - o7 - i.0/- 003.75� 4 �8
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
x
Signature of applicant Address of applicant (number and street,ay,state,and ZIP code) r
1\ A/zawm 1e. rf ohe-tc.cz, r?I-- �C Log gr. t s S.t.�.c,r' !it>&n.c.ct , 1Nr Y777O
Signature of authorized representative Address of authorized representative (mmrberand street sty,slate,and ZIP code)