HomeMy WebLinkAboutDisabilty_Diel .,,f ,
t,_.: APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Fans 43710(R9/9-08)
Prescribed by the Department of Local Government Finance
V r
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). e i-
INSTRUCTIONS: 4.
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought. 0 Ci 1 2.015
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properzy:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner untract buyer) 1I1r�,�11� •L`/_/��11{'y x1(/^/1 ,y"1y, G(ggON COUNTY AMA"tn
Is applicant the sole legal equffa a own // If No,what is his/her exact share of inert I(omed with someone other than spouse,
_ VVV indicate with whom:
❑Yes
If name on record is different than that of applicant,indicate bebw:
Name of contrad seller
Address of contrail sager(number and street,city,state,and ZIP code) Is the property in question
❑ RS Property ❑ Annually Assessed
Mobile Hume(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 inlul activity
as defined in IC 6-1.1-12.11(d)?
ID Yes o es ❑No
Is the property used and occupied primarily for h^ er residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
es ❑No ❑Yes No
Taxing district Key number/Legal description I Read number Page number
n1 26 — )o-36-tt- a01.1e1-t2
IIWe 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 a Address of applicant (number and street,city,state,and ZIP code) 4.
Q� 3(5I S 70o 0-4,44 (42001/45--
n ure of aulh ' re sedative Address of authorized representative (number and street,city state,and ZIP code)