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HomeMy WebLinkAboutDisabilty_Warren • APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR :PI DEDUCTION FROM ASSESSED VALUATION State Form 43710(R91408) Prescribed by the Department of Local Government Finance Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark INSTRUCTIONS: To be filed in I person or by mail with the County of county where the property is located. �.•) Filing Dates: 1) Real Property:During the year for which the deduction is sought. �1 p '� f ) 2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Re p�u�nri the twelve(12)months before March 31 of each year the individual wishes to obtain the deduction. 2 r� c See reverse side for additional instructions and qualifications. JUL 2 1 2016 Name of ap �owner or contract bbuyer)p GA ACAOLEL It5 I ` 0..A-41,/}-\ ) TTyvr �e'' OR Is applicant the sole legal or equitable owner? If No.what is his/her exact sham of interest? �t�I '�dlier'd,u spouse, h wtiom Yes ❑No If name on record is different than that of appicant.indicate below: Name of contract seller Address of contract seller(number and street,city,state,and ZIP code) Is the perry in question: Real Property ❑ Annually Assessed 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 substantial ' fiat activity as defined in IC 6-1.1-12-11(d)? ❑Yes ❑No Yes ❑No Is the property used and ocwped primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year exceed$17,000? ❑Yes ❑No ❑Yes No Taxing district Key number/Legal description Record number Page number C26/ — l 8 .0'7- /DI - 000. 5/)o-vaa lfWe 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) ' ,� e-�/ Li o 6 1 C ©; at ioGhs" na re of authorized representative Address of authorized representative (number and street,city,gate,and ZIP code)