Disabilty_Carter APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
glItt; DEDUCTION FROM ASSESSED VALUATION T
State Form 43710(R9/908) 1
escribed by the Department of Local Government Finance '
Pr -
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). OCT le Nits
INSTRUCTIONS: [��J
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 �1/�� a
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:Dathi:'I - •r 4t'�t ffittl3.0efore
March31 of each year the individual wishes to obtain the deduction. GIBSON COON
See reverse side for additional instructions and qualifications.
Name of applicant(own or tract buyer)
Dia,a_ oAcc_ctbuicA,
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
Yes ❑No
If name on record is different than at of applicant.indicate bebw:
Name of contract seller
_ _
Address of centred seller(number and street,city,state,and ZIP code) the property in question:
Real 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 1ANo �,( l,Yes ❑No
Is the property used and occupied unmanly for his/her residence? Does Ih`e(`([pplii antt's taxable gross income for the preceding calendar year
exceed S 7,000?Y"^ ❑ ❑ ,,,,,,mmmmmm---------��t111,,,,,,
Yes No Yes ilNo
Taxing district Key number/Legal description Record number a number
1/4)"1" bk A ab-I3-a4-aDa-0gb•S37-0014i
IfWe 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 .
Sgnatu` •• applicant Address of applicant (number and street,city, tate,and ZIP code)
/III(_] C1
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Signatu of auhprized representative Address of authorized representative (number and street,cif .e,and ZIP code)