Disabilty_Lincolnl`
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"" APPLICATION FOR BLIND OR DISABLED PERSON'S
' DEDUCTION FROM ASSESSED VALUATION
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Sta�e Fortn 43770 (R9 / 9-OB)
Resaibed by Ihe DapanmeM o( Loml Go.emmern Fnance
COUNTY TOWNSHIP YEAR
I�wmatbn containetl in Nis docvment is CONFIDENTIAL pursuant to IC 61.1-12-12(b). NOV 1��I[�� I
INS7RUCTIONS: �
To be filed in person or by mail with fhe CountyAuditor o/ the county where the property is locafed.
Filing Dates: 7) Real Property: Dunng the year for which the deduction is sought. I
2) Mobile Homes assessed under IC 57.1-7 or Manufactured Nanes not assessed as Re�F�������ths before
Maich 31 01 each vear fAe individual wishes to obtain tAe deductiar. �
See reverse side /w additional inshudions arrd qualifications. I
Martre of aGP�wn� (oxnar or mntract buye�) � /,// t
< ���' `i ^!_ _ / ° `i I
Ls app6rafn ttre sde legal or eQUilable awne . If No, what ¢ Ivs/her ezacl share d interestt Q o�med wiTh m�reone other Ihan spouse,
indiete with whom I
❑ Yes ❑ No �
I( name m�emd is diRarem Nan Ihat d apdimnt, iMicata beb+r. � '
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Nama d mntratl se0er � (
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Pddress d mnbatl se0er (nvnbrl and stree[, ciry, sb�, aM Z/P code) Is Ne property in que5ion: I
❑ RealProperh' ❑ Anrwa�v/�sse�ed
Mohde Home (IC 61.1-7)
I5 appMa�n 6Gntl as defined in IC 12-7-2-21(1)? Ls applimnt disabled and unade to enqage in arry wbstamial gairdulatliviry
as defined in IC 61.1-1247(d)? i
❑ Yes ❑ No ❑ Yes ❑ No
Ls Ihe propeM � a�W ocwpied primarily for hidhar resdarica? Ooes Iha aPdipM's lazable y�s inmme (or L`.e preceding qlend�r Y�r
ezwed 517,0007
❑ Yes ❑ No ❑ Yes ❑ No
Tatirg d'avitl Key numEer / Legal desaiplian Recrnd numbar Pagainumber
(./" G�f `d�` � . / �o - .JO . ) 7 7 — � O/ � — O � I
IIWe certify under penalty of perjury thaf the above and foregoing information is W e and cortect and tha[ the applicant i as a resident
of Indiana and owner of the aforementioned property on March 1, 20
Sign�ure W appGcanl Address of applimrif (numbu anE sbeel, ciry, sfa�, and ZIP code) �
� ia6 s� er aC �
sy�a�u�e or oraed rep�esemawe nearess or au�tor�d rec.esa�,�ira �numaer sLCe4 u�}; 9ate. an0 LP rntle) �
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