HomeMy WebLinkAboutDisabilty_Donaldson °" APPLICATION FOR BLIND OR DISABLED PERSON'S couN1 fH
DEDUCTION FROM ASSESSED VALUATION
• Slate Forth 43710(R9/408)
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Prescribed by the Department of Local Government Finance C
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). Mb Clark 2016
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Proper iaseIt ecrati 91TlY)/hblikblQ&e
March 31 of each year the frdNidual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
LID —
C'S'R.a o J�^1_�y C
Is applicant the sole legal or equitable owner? / No.what is his/her exact share of interest? ff owned with someone other than spouse,
indicate with whom:
ees ❑No
If name on record is different than that of applicant,indicate below.
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) I the roperty in question:
eat Property ❑ Annually Assessed
Motile Hare(IC 6-1.1-7)
Is applicant bfind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
,,��QQ as defined in IC 6-1.1-12-11(d)?
❑Yes o 'es ❑No
Is the property used and occupied primarily for his/h residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
IfYes Yes ❑No *es 'o
Taxing district Key number/Legal description Record number Page number
da-bit-2 Ll-3614-o0l 44G-0i a
IMe 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,state,and ZIP code)
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O O A - dl _p- o_
Signature of authorized representative Address of authorized representative (num•- and street city,state,and ZIP code)