HomeMy WebLinkAboutDisabilty_Henrich APPLICATION FOR BLIND OR DISABLED PERSON'S cou ��S�ia�i!�;IL�.`-�
DEDUCTION FROM ASSESSED VALUATION �'
'� State Forrn 43710(R9/9-08)
Prescribed by the Department of Local Government Finance • o
r
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: �!
To be filed in person or by mail with the County Auditor of the county where the property is located.
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Filing Dates: 1) Real Property:During the year for which the deduction is sought. COUNTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instruct)ons and qualifications.
Name of appfica or contact buyer) / -
&AAA/a ( i ll�dc-)
Is applicant sore legal or equitable owner? If t No,what is his/her exact share of interest? If wined with someone other than spouse,
indicate with whom:
❑Yes ❑No
8 name on record is different than that of applicant.indicate below:
Name of contract seller
Address of contract sever(number and street,thy,state,and ZIP code) Is the property in question:
❑ Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any su tantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes - No Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the eceding calendar year
exceed 317,000?
4Yes ❑No ❑Yes ❑No
Taxi tore ) Key number/Legal desaiplbn Record number Page number
Taxi
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IfWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20 .
Signature of applicant Address of applicant (number and street,city,stale,and ZIP code)
Ala, $ it_-L ?Vick w,)AI.im--;t53 .O1,,ew1.1,„/4., y7{c65
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)