Disabilty_Kendle it ?!.. , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R9/9-08) FILED
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: NOV 2014
b be filed in person or by mad with the Courtly Auditor of the county where the property is located.
Filing Dates: 1) Real Property.During the year for which the deduction is sought /LI,• _ :g _- (12)2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not as tnccad as Re • (,•. •;raj_ AUDI(12)months before
March 31 of each year the individual wishes to obtain the deduction. T R
See reverse side for additional instructions and qualifications.
Name of:AI,. nt(owner or contact buyer)
•
o
Is applicant the sole legal or.• ,...:. If No.what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑yes No
If name on rend is different than that of appOcant indicate below:
Name of contract seller
Address of mntraa setter(number and street city,state,and ZIP code) Is the property in question:
AnnuallyAssessed
Mobile Home(IC 611-7)
Is applicant blind as defined in IC 12.7.2.21(1)? Is applicant disabled and unable to engage In any substantial gainful adMty
as dented In IC 6-1.1-12-11(d)?
OgYes CSI No ,®Yes ❑No
Is the property used end occupied primarily for hiseber residence? Does the apolic ant's taxable gross income for the preceding calendar year
exceed$1 ,
liar/es ❑No ❑yes No
Taring Key number I Legal description Record number Page number
141.,(Aq/e-e-1 .-1 2!o -/d -08 -Jo/- °°1 v(8-oa ?
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,state,and ZIP code)
KkallaA0// �Do x hlg 6.�1OU 5 �-. ))Alyr d 41eia
Signature of authoriYkd Address of authorised representative (number and street,dry state.and ZIP code)