Disabilty_Miller APPLICATION FOR BLIND OR DISABLED PERSON'S i TO YEAR
DEDUCTION FROM ASSESSED VALUATION
- State Faun 43710(R9/9-08) 2 1 1
Prescribed by the Department of Local Government Finance OF
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). APR r7 ile MI5
INSTRUCTIONS:- n
To be filed in person or by mail with the County Auditor of the county where the property is located. /x+'t2'
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 RiklattotscoeumwAuv peep before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications
Name o Plicanl(owner or contract buyer)
Is
Is appli t the sole regal or equitable owner? If No,what is histher exact share of interest? If owned with someone other than spouse,
indicate with whom
❑Yes ❑No
If name on record is different than that of applicant,indicate below:
Name of contrail seller
Address of contract setter(number and street,city,slate,and ZIP code) ts the property in question:
❑ Real Property ❑ Annually Assessed
Mobile Horne(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 El No ®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$17,000?
In Yes ID No ❑yes ❑No
Taxirpftisttict Key number/Legal description Record number Page number
t,t e�w JO '947 —J - - Yoo - 00/. .336 - o .c7
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 and
A 139 t a 5o 97407
Signature of authorised representative Address of authorized representative (number and street,city,state,and ZIP code)