Disabilty_Koelling (2)!"
APPLICATION FOR BLIND OR DISABLED PERSON'S couKrv TOWNSHIP � YEAF2
- DEDUCTION FROM ASSESSED VALUATION
.. S1ate Fortn 43710 (R9 / 408)
.� �
Presaibed by U�e Dapartmenl ot Loml Go�emmertl Fnance
Infwmation wnfained in Ihis docvmen� is CONFIDENTIAL pursuant W IC 6-1.1-12-12(b). File Mark :���
iNSrnucnoNS: NOV 4 2015�
To be filed in persm or 6y mail wilh the CounlyAuditor o/!he county where tlie property is /ocated.
Fding Da�s: 1J Real Pioperty: Dunng the year for which the detluctbn is �ught.
2J Mobile Hwnes assessed under IC 57.1-7 or Manufacfured Homes not assessed as Real Property:
March 31 of eech year the individual wishes fo obtain the deduction. GIB $
See reverse side fw additional insWdions and qualificatiara
Name of appfi�r� lowner ar conLac(Wys�J •
Is app6cam the sde iegal or apuitaMe owneR
� Yes
If name m record is diRerent Ihan Nal d apqi
Name of mnad seDer
contraa
Is apptimN bGM as defineE in
If No, what is hivher
�No
ind"xate belw`
street, city, slate, aM ZIP mda)
❑ Yes � No
Is Ihe propeM �� arW occupied primanly for his/her resitler�ce?
�Yes ❑ No
Taxirg d"atria Key number / Legal Eesaiplion
ot �xaresn
H oxned with somema dher Uan
iMfnta wilh wirom
Is Ne propery in que5ion:
�' F2eal H'operfY ❑
Is applimM diubled and unabla ta engage in arry wbstarrtial
as defined in IC 6t.7-12-77(d)?
� Yes
Oces ihe applicanPS 1ar.aWe gfoss incon�e br the pec�ading �
ez�etl 577.0001
❑ Yes �
Rernrd number Page
manths 6efore
(IC Cr1.
UWe certify under penalty of perjury that the above and foregoing information is We and correct and that the applicanf ias a resident
of Indiana and owner of the aforementioned property on March 1, 20
syna�ure d a�riram Address ot applimnl (niunbrr ar�d sbeef, ciry, sbfe, a� LP code) � l I i/J �
Signature
n
AEdress of authorizeC representalive (numbai arM sGee4 city, 9ate,
`•)