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ki�s{, APPLICATION FOR BLIND OR DISABLED PERSON'S coui of TOWNSHIP YEAR
' DEDUCTION FROM ASSESSED VALUATION
vxoi Fwm 43710(R9I9-08)
Prescribed by the Department of L o c a l G o v e rn m e n t Finance $1 7 i■�
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). r ' -,t ' i Or
INSTRUCTIONS: I,1
To be filed in person or by mail with the County Auditor of the county where the property is located. NOV 2 4 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 Properly:Dury e twel (12)months before
March 31 of each year the individual wishes to obtain the deduction. �(�p,♦N
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Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ RS Property ❑ AnnuaqyAssessed
Mobile Horne(IC 6-1.1-7)
Is applicant blind as defaced in IC 12.7-2.21(1)? Is applicant disabled and unable to engage In any subslantal gainful activity
as defined in IC 6-1.1-12-11(d)?
El Yes ID No ❑Yes CI No
Is the property used end occupied prima*for heftier residence? exceed 51
156es El No ❑Yes El No
Taxing district Key number/Legal description Record number Page number
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
Signature of applicant Address of applicant (number and street city,state,and ZIP code)
A a AAA 89 Of t
.e Ast„t..4141_„4 3,r)6 S Ma f-fe% S SMncA TM
Signature of authorized representative Address of authorized representative (number and street,sty,state,and ZIP code)
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