Disabilty_Conder APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
— --t.; DEDUCTION FROM ASSESSED VALUATION
Pre rant 43710(e9/9-06) ��� �
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:
Prescribed by by the Department of Finance
Government ance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: APR 2 7.2015
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. ' /l"''`�1
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real ProperjyD uri pr &rEls afore
March 31 of each year the individual wishes to obtain the deduction. GG $QN CO(Jf�Y.�+Y�[�P
aUDIT
See reverse side • additional i ructions and qualifications. OR
Name of ap• / or or contract b yet) &-e,f Is appf.'nt • egal or equitable owneR If N hislher exact share of interest? If owned with someone other than spouse,
it
indicate with whom:
❑Yes ❑No
If name on record is different than that of applicant.indicate below:
t
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP robe) Is property in question:
Real Ptuperfy ❑ Annually Assessed
TTT���•••
Mobile Home(IC 6-1.1-7)
Is applicant blind 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 ❑No ❑Yes ❑No
Is the property used and occupied primarily for higher residence? Does the applicants taxable gross income for the preceding calendar year
exceed 517,000?
'Yes 0 N ❑Yes ❑No
Tax" districts /� • Key number I Legal description Record number Page number
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07412-12110?—O 3o Oo
I/We certify under penalty of .iv
the t the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the a entinned property on March 1,20 ��.11 \1
Signature of applicant Address of applicant (number and street,city,state,and ZIP code) / II Ll
7S &- -- K .-hli vd A ,cam c c f - • «l///
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code) 4-40,00