Disabilty_WilliamsC`
7'+� :�
APPLICATION FOR BLIND OR DISABLED PERSON
DEDUCTION FROM ASSESSED VALUATION
sa�e F«m aano �RS i sae�
Prasai6ed by Ne Department of Local Govemrtrent Fnanca
tn(wmation contained in Nis doament is CONFIDENTIAL pursuant to IC Cr1.1-12-12(b).
INSTRUCTIONS:
To be filed in person or 6y mail with the CountyAuditor of the wunty where tl�e propeily is
Filirg Dates: 7J Real Property: Dunrn] the year (or wh,ch the daduclion is sought.
2) Mobile Hwnes ascessed uiMer IC fr1.1-7 or ManNacfuied Homes no
Maich 31 of each yea� the irMividual wishes to obtain the deductlm.
Sae reverse side for additronal insWCfions aiM aualifications.
Namemacavm�ownrro.00�r2aw,l�n^ .
`_�Y� /� �
Is applimm itre sda legal or aQUilable owneR H No. what i5 his�her esad Shara of imerestt tl ameE wiih mrteme dher lhan s Ise,
iMiote with whom
❑ Yes ❑ No
If name on racord is diRe�anl Man Nat of appirant, indkate bebx: I
Nama of contacl seDer I
Pddrass d mntrad seDer (num0er aiM street, cAy, sla�. aM ZIP code) 6 Ihe properry m 0uestion:
❑ RealProperty ❑ anrniauyassessea
Abdle Fiane (IC 61.1-�
Is applimrtl �Gnd az defined in IC 12-7-2-27(1)? Ls apqimm Cisabled and unada to ergage in arry substanlial gairiWl a�liHty
as defined in IC 61.1-12-11(d)7 I
❑ Yes �No ❑ Yes ❑ No
Is Uie proparry used anC orsupied primarily for his/her rasdence? Daes Ihe apd�nfs tarable gross income for Lhe precedifg �aknda( year
escaed 517.OD0? I
�Yes ❑ No ❑ Yes ❑ No
Tazing d'avict Key number / Lagal desaiption Recmtl numbar Page number
��.�rv �6-ao-// -/DD-DDD. `� 5�-00� I
I/We certify under penalty of perjury lhat the above and foregoing informa6on is W e and correct and that the applicant i as a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature d appifam _ Addrass of appticam (numbuaiW sheof, ciry, state, anE LPmda) I
- y76co
� X - , ,' ��
' nature o( aulhuacN representative PdErass of auihonmd representative (number aN shee4 �Y, ��e, and LP cade) I
�
�`