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°"' APPLICATION FOR BLIND OR DISABLED PERSON'S
. DEDUCTION FROM ASSESSED VALUATION
•' .: ,
Sfate Fam 43710 (R9I408)
Presaibed by ihe DepaAmeM d Laal GovemmeM Fnanca
Infortnatiom m�tained in this docvmen[ is CONFIDEMIAL pursuant to IC 6-1.1-12-12(b).
INSTRUCTIONS:
To 6e h7eAin persm or by mail with the CountyAuditor of the county wheie the property is located.
Filing Dates: 1) Real Property: Dunng the year for whkh the deduclion is �ught.
2) Mobils Homes assessed under IC 67.1-7 or ManNactured Homes not assessed as Real
Maich 31 of each year tlre individual wishes to obtain the deduclion.
See 2verse sitle fw�adddional iutnidions arrd qual' tions.
Name of appfic�am ar cmhact bul'erJ � /7 _
Is appfimm IT1xde leqal ar equitable owneR
❑ Yes ❑ No
IF name on recwd is diRerem ihan tha� of appirant, indic
Name of mntrad seller
Address of mntrad seller (num0er
sFale,
Is appliraN blinti as defined in IC 12-7-2-21(i)?
i: me
ra:ne
Yes
H No. whal a his/her
Yes ❑ No
Key number I Legal Eesaiplion
Property: Dt�i p thB MgWe 1fj�j�s 6efae
of imarasY! tl owne0 wiU someone dher ihan
indiGate wilh whom:
Is property in question:
Real Property � Mnual
Mohde
Is applirvnl disabled aM unable lo ergage in a�ry wbsfaMial gai�
as defined in IC G7.1-1241(d)?
�es ❑
��
Does the appli�an�'s taxabie gross income br t�e preceCing plend�
ex�ed 517.000?
❑ Yes ❑
_ RervrE number Paoe
i"�/UiX�.fr�v ol/ol /�-O/ 3G7`= aa/. 76a-��Z11 I
VWe certify under penalty of perjury that lhe above and foregoing infortnation is We and wrtect and that the applicanl
of Indiana and owner of the aforementioned property on March 1, 20
ignature d�fn Pddress of applimM (moMer and sbael, ciry, sfa�, md LP code)
= V� /��f � f.�/�n�� S / i°�'i�
Adtlress ot aulhor¢ed representative (numbw ard sLeel, r�ty, slate, LP wde)
is a resident
y7� �a
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