Disabilty_Jackson 4--(4,": APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY F P YEAR
1a DEDUCTION FROM ASSESSED VALUATION L 1
Slate Form 43710(R9/9-09)
I
Prescribed by the Department of Local Government Finance "Pal
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). ,ra 1 ry' 2015
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought. Jl1J7jj
2) Mobile Homes assessed under IC 5-1.1-T or Manufactured Homes not assessed as Real Property:giR§ON incyki
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer) /lam //'
Is applica :sole legal or equitable ovneR/ If No,what is hivher exact s "are of interest?c V If owned with someone other than spouse,
indicate with whom:
Sees ❑No
If name on record is different than that of applicant indicate below:
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) LsjtheiloeM n question:
a
Property ❑ Annually Assessed
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 tYes ❑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?
'es ❑No ❑yes No
Taxing district Key number/Legal description Record number Page number
&corll-(a-2ck�- CrS�. 3$ 43g
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)
AAL - (1)2Prit •9011 k 9 Pc 5 f' �140(to -j
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)