Disabilty_Field r 5.;.! , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
reigrl DEDUCTION FROM ASSESSED VALUATION
State Form Kano(ep/9-06) ' _VI_.. .
Prescribed by the Department of Local Government Fnainoe
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). - ;i .' •
INSTRUCTIONS:
To be filed in person or by mad with the County Auditor of the county where the property is located. JUN 1 9 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 Props During a Iva 12 months before
March 31 of each year the individual wishes to obtain the deduction. G IBSO
See reverse side for additional instructions and qualifications. N COUNTY AI IntTOR
Name of applicant(owner or contrast buye
SGe_ k„) u . e_id
le 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 whom:
Yes El No
If name on record Is different than that of applicant,Indicate below.
Name of contract sager
Address of contract sager(number end sbee4 city state,and ZIP code) Is the properly in question:
T9 Properly ❑ AnnuallyAssessed
Mobile 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 substantal gainful activity
y, as defined In IC 6-1.1-12-11(d)?
El yes bNo ❑Yes g3 No
Is the property used end occupied Omer*S his/her residence? Does the eoofcanfo taxable gross income for the preceding calendar year
exceed Si .000?
❑Yes ❑No ❑Yes ENo
• district Key number I Legal description Record number nrmmber
, . Z(o-Z3- I8- I06-0a0 Sao -c�aq
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
Address of applicant (number end street,city,state,and ZIP code)
X D:3 ccJ 1 ado /imulb5<�d-7, °Uar39
Yof authaaede<\ repn serrtative Address of authorized representative (number and street,city:state,end ZIP code)