Disabilty_Chavis° APPLICATION FOR BLIND OR DISABLED PERSON'S
, -- : DEDUCTION FROM ASSESSED VALUATION
- Stale Farm 43710 (R9 / 4O8)
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�+ Presaibed bY �he DaGa�iment of Laml Go�ernmerit Frunca
Infwmation containeE in ttis dowment is CONFIDENTIAL pursuant to IC G1.1-12-12(b).
� SHIP YEAR
DEC 2 2015 F11e Ma'k j
INS7RUC710NS: �
To be filed in person or by mail witli the CountyAud'rtor ol the county whera tlie property is bcafed. � j
Filirn7 Dates: 7) Real Property Dunrrg the year fa which tAe dedution is so�ghG �— i
2) Mobile Homes assessed under IC 6-1.7-7 or Manufactured Homes nW assess�4i��1 ��ASry�j(7pp�'� (12)�montlts 6e/ore
March 31 0/ each yea� the irrdirvidual wishes to obtain the deduction. r
See raverse sitle for atldilional insWdions arM qualifications. I
Nartre d a7 'i rtl (owner ar cmfract buyeQ �
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Ls appGam the sde legzl or equitahle ownaR If No, whal is h�sTher ezaG share of imeresiT H owrred with mmeona othar Ihan spousa,
i(dimle wilh whom I
❑ Yes ❑ No I
If �ame on remrd is diRerertl Ihan Ihal d aPamnt. ifWicate belrnr.
yC.-�� G� �-Q-�-
Address d mntrad seller (number and sboe4 ciy, sfate, ad LP mde)
Ls aPG�m bliM asdefined in IC 12-7-2-21(1)?
❑ Yes ❑ No
Is Iha pmperry usetl aM occuped pnmanly for his/her residexe?
Yes ❑ No
Tazing d' irid ` Key numGer I Legal des�
�/1,�r.c1'�`� A6 �l � -D 7 -
i� Na woaem � a�a��,: I
❑ RealPro�erty � nnnual'yPssessed
MchBe Home QC E1.1-7)
Is applicant disabled aM unable to engage in ary wbstantial gaiNul artiviry
as dafinBO in IC 61.1-12-N(d)? �
❑ Yes ❑ No
Doas Ihe appliram's IanaWe g(oss income br t�e preceE'vg fale�ar yaar
exreed 517.0007 �
Recwd number
/—DO.3.�s8�o1�8
❑ Yes ❑ No
Page number
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I/We certify unde� penalty of perjury thal the above and foregoing information is We and covect and that the applicaM,was a resident
of Indiana and owner of the aforementioned property on March 1, 20 �
ndaress of awumm f��eerar�d:�at r.rtr, sa�e, a�e z�a��
Signalure daulhw¢ed reprp�anWtive � Address
S�MI���- f Q1t�C�
representaWe (numG�aitl sLeet, ciry, s! e. anC
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