HomeMy WebLinkAboutDisabilty_Klusmeier (2) e ti,l APPLICATION FOR BLIND OR DISABLED PERSON'S co YEAR DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R9 19-0S)
• -'�+ Presorted by the Department of Local Govertvnent Fnance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). JAN F 3 M G45
INSTRUCTIONS: /�� n A�
b be filed in person or by mar!with the County Audrtor of the county where the property is located. J lL,,,,, /-
Fill g Dates: 1) Real Property:During the year for which the deduction is sought gg 7t1,I�d �pn*-�uMH4.P
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real PropGel 191ifrlrn9tllygaltleM before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side @ additional in -' and qualifications.
Name of applicant(owner or contract buys
Is a the sole legal or equitable _. If No,what is his/her exact share of interest? U ' owned with someone other than spouse,
vindicate with whom:
❑Yes ❑No
If name on record is different than that of applicant,indicate below.
Name of Centred seller
Address of Centred setter(number and street city,state,and ZIP code) Is the property in queslan:
❑ Real Property 0 AnnuagyAssessed
Mobile Home(IC 6-11-7)
Is applicant band as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage In any substantial gainful actMty
as defined In IC 6-1.1-12-11(0)?
❑Yes ❑No _ CI Yes No
Is the property used end occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,0007
El Yes No ❑Yes No
Taring Key number I Legal description Record number Page number
/ C —/ -1/a3ao- 00/.7/6 -0a/
•/We certify dy u - pane o perjury m
at the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of I - aforementioned property on March 1, 20
Signature of applicant Address of applicant (number and street Uy,state,and ZIP Cede) "
iat�iness 2, /7,85 , 550„- of �.vs „/��� 1, `-1765 767
Signature of authorized representative Address of authorized representative (number and street city,state,and ZIP code)