Disabilty_Jay ,r APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
�
� 1?' ' DEDUCTION FROM ASSESSED VALUATION
Prate Form d by 43710
the Ra l sox) FILED
Presamed by the of Loral Govertmkmt Fv
Information contained m this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: JUN 2 7 2014
b be filed in person or by mad with the County Auditor of the county where the property is boated.
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 6 OSO fns before
March 31 of each year the individual wishes to obtain the deduction. COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Name of a (owner or contract buyer) ^ /���/f/��f�/,,
is applicant the sole equitable 1 Y71y) If No,what is hismer exact share of interest? If owned with someone other than spouse,
indicate with*from:
❑Yes ❑No
If name on mead Is different than that of applicant,indicate below:
Name of contact seller
Address of contract seder(number and street,city,state,and ZIP code) Is the property in question:
0 Real Property ❑ Annually
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 substantial gainful adrvity
as defined in IC 6-1.1-12-11(d)?
El yes No El Yes No
Is the property used end occupied primarily for huffier residence? Does the applicants taxable gross income for the preceding calendar year
exceed$1 1.tltt?
14 Yes ID No El Yes El No
Taxing district Key number I Legal desaipton Record number Page number
24' -/9. 31 - 30/-000. 3595.009
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
Signaoae of n�� / Address of applicant (number and sheet city,slate,and ZIP code)
P.\ ,/ Z 061 ,,s • M t p c w k f K} % T
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Address of authorized representative (number and street,Sy,state,and ZIP code)