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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
', � sra� Fam aa�io �res i soe�
Praunbe0 by Me OeD��h d Lod Gm.emrnenl France
Informatbn containeC in this doaiment is CONFIDENTIAL pursuant to IC Cr1.1-72-12(b).
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INSTRUCTIONS C .'�. Ma�y
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To be fileU in person w by maii wvth fhe CpintyAudifp� of fhe county wfiere Me p�operfy is bcated. �V v
Fdirg Dates: 7) Real Property: Dunrg the year (or which the Geduclian is sought G I BS ON COUNTY AU DITOR
2) Mobile Hanes assessed uMer IC E 7. 7-7 or Manulactwed Homes nof assessed as Real Properly: Durirg lhe (weHe (12� montl,s nefae
Mamh 31 d eacA year the irMividuel wishes to o6Fain fhe dedrxtip�.
See reverse side far adddional insWdions and oualificafians.
Narne zod�alo.+marcwrauev}ar)
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k fimM the stle legal or ea de wmeR M No, rfial s hisfhm esacl shara d iirtarast7 tl owned wilh someone other Nan spoum,
intlimla wifh wMm
❑ Yes ❑ No
C nama m remd'u d'AareM Ihan Ihat d aVP�t intlirate Oeb.r.
Nartie W toniracl SBOer
AddRSS N mntrad m0er (imnDU an0 sbecL �y. sbb. and ZIP oodo) ¢15ye ppp¢r1y in quasfion:
L� R�I P�Ay ❑ MrwaBYAssessed
Mohde Flort�e (IC 6-1.1-7)
Ls app&aM bGld as defineE in IC 12-7-2-21(1 �? Ls applioM disablad ard unade to ergage m arry wbstantial gainlul atliviry
a5 defire0 in IC 61.1-72-N(d�? ,�(
� Q Yes �No �y Yes ❑ No
Ls Ne propeM �s� ���P� P��Y br hisTher rasidence? Doas �he appli�'ariTS lasable gr�s incana (or tha pretetling oleMar year
esmeC 517.000?
�Yes ❑ No ❑ Yes ❑ No
Tasing disUic� Key numDer / Lepal desaiplion Record number Page munber
^ dG- I`f-D'1-Yoo_ �ol. 4 18-�°�
I/We certify under penalty of perjury lhal the above and foregoing ioforma6on is W e and corcect and that the applicant was a resident
of Indiana and owner of the aforementioned property on Maroh 7, 20 _
Signature d apptica�v Addrass of appGrant (�nOrr antl st�oot, aty, slafe, and ZIP cotle)
ss a E D.a �,� � r y766o
rada resentativa Addrassofaulhorizedrepresentative(nunDeraitlsLOef,cify, afe.anOLPCatic)