Disabilty_Rawlinson"' APPLICATION FOR BLIND OR DISABLED PERSON'S
:. -� : DEDUCTION FROM ASSESSED VALUATION
- Sta� Form 43710 (R9 / 9d8)
.� �
�+ Resaibed by Ne DeparlmeM of Loml Grnemmem Fnanca
�wmatbn contained in this tlocument is CONFIDENTIAL pursuant to IC Fr1.1-72-12(b).
�NSrnucnoNS:
To be filed in persm or 6y mail wilh the CountyAudrfw of the wunty where the property is locafed.
Filirg Dates: i) Real Property: Dunng the year for which fhe deduction is sought.
2) tao6de Homes assessed urrder IC 61. iJ or Muwfactured Hanes nU assessed as Real
Maich 3f W each year fhe individual wishes to obtain fAe deduction.
See raverse side fw additional instrudions a�M quali6cations.
Name ofjpql'ram (owrier w cronvact buYer) .-.
stle legal or aquitade owneR � tl No, what is hislher exaG share d i�riarest?
LJ Yes � No �
M�ma on remrd'a diRe2n1 �han Ihal d applifant, indifate bebw:
Namadcaniracl e0er
C�
Pddress d mntra seDer (numbtr arM sbeet. crty. sta�. a�C ZIP c
Is applifarit bGnd as defined in IC 12-7-2-21(1)?
UYes �f No
propeM � a� arupieL primarily for his/her re
❑ Yes ❑ No
disiricl
Key num0er / Legal Eesaiqian
fC
COUNTY TOWNSMIP { YEAR
� � � i
DEC f�����`�
1
rry: � y�5
Ri850N N UbIl�Rbetore
i
I
freE wiih somema dtrer Ihan sGasa,
Is t�e 7�PQM in vuestian:
❑ R� �rovenv ❑
Is applicant disabled and unaWa to engage in arry wb5lanlial gairik.�
as defined in IC 61.1-12-11(d)9
� Yes ❑
Ooes lha applipM's �anabla gross incvrt�e br Ihe preceEing plend
ex�aed 517.000?
❑ Yes �
�76-oa I
IIWe certify dalier penalty �perjury that the above and foregoing information is We and correct and thal the applicanf
of Indiana and owner of the aforementioned property on March 1, 20 .
5gnaturaofappfvr:t Pddresso(appGCam (numb�aMSbeet.ary,sfafe,a+dLPmOe)
%C��-1,a.Lf'�,p `",��„-P��,�� /.?B� SOI�(S'Exfe�G3 j�iNcefok,/N
Signature W aulhoraed represantative AEdress of aulhwrsed �aprasenfative (n�mbeiarM sheef, city, stafe, andLPCrode)
r�
a resident �
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