Disabilty_Garrett ç; .: APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
1 j DEDUCTION 43710(R101&14) IT FROM ASSESSED VALUATION F ' F' D
Slate Farm �-1
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. OCT i 5 2015 File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is •r ed..
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 .y;,(.;r `+G miler::rked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured HqS100 4*sus TA 3' :. 'At EThoeffr During the hveive(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(\ow/ner&ccontract buyer)
Y fax\ K • \—)0rre:AA
Is applicant the sole legal or equitable owner? If No,what is hismer exact share of interest? If owned with someone other than spouse,
indicate with whore:
9Yes ❑No
If name on record is different than that of applicant,indicate below
Name of contract seller
Address of conoed seller(number and scree;city,state,and ZIP code) Is the property in question:
5:1 Real Property ❑ AnnuafyAssessed
Mobile Home QC 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 his/her residence?
Record number(contact) 'Page number(contract)
.**42.1A/net 2/0-/s-2.9 - zo'I cell-o a 6
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant t 1 Address of applicant (number and street,city,state,and ZIP code) �t
-) \ L\ \� � `O \ E - � .5� VA J(Q-V\C\ �� �el(pLi
Signature of authorized representative Address of authorized representative (number acrd street ray,state,and ZIP code)