Disabilty_Kelley ...4' t*>s APPLICATION FOR BLIND OR DISABLED PERSON'S --C YEAR
, DEDUCTION FROM ASSESSED VALUATION
`-• State Form 43710(R9/908)
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Prescribed by the Department of Local Government Finance 1 �I�CxA
Information contained in this doament is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). APR 1 H45lark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the properly is located. '
Filing Dates: 1) Real Property:During the year for which the deduction is sought.
2) Mobile Homes assessed under IC 6-7.1-7 or Manufactured Homes not assessed as tP®Ir1Aljrtwek oil jardlonths before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of app&canl(owner or contract buyer) ,,./]y1^J�1
J 1 `
is applicant the sole legal uila ' r? , If No.what is hivher ex share of interest? If owned with someone other than spouse,
indicate with whom
VYes ❑No
If name on record is different than that of applicant,indicate beta:
Name of contract
I' �/-r.�(�
Address of contra seller(number and street city,ate,and ZIP code) Is the property in question:
❑ Real Property ❑ MnuailyAssessed
Mobile Name(IC 6-1.1-7)
Is applicant bend as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ( •Io TEgt,Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
❑Yes No ❑Yes tglNo
district Key number/Legal description I Record number Page number
)1/4-51001^- -a3-07-4CO- 000•I(OS- cy
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)
V)C. / 0 / 2' /1/58 F/Ace S )4451; e rr• x7631
Sign,A of representative / Address of authorized mmasentative (number and street,city,state,and ZIP code)