HomeMy WebLinkAboutDisabilty_Graham CAPPLICATION FOR BLIND OR DISABLED P S � COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATIONg1
State Farm 43710(R9/408) 1
Prescribed by the Department of Local Government Finance `1 2016
Information contained in this document is CONFIDENTIAL pursuant to IC&1.1-12-12(b�0 V File Mark
INSTRUCTIONS: ��,J •
To be filed in person or by mail with the CounlyAuditor of the county whem the grope -
Filing Dates: 1) Real Property:During the year for which the deduction is swig COUNTY AU � r'
2) Mobile Homes assessed under IC 6-I.1-7 or Manufactured} es not assessed as Real Property:During the(we e 1 )f .- before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contact bayed
Is applicant sole legal or e ita owner? If tlo,what is his/her exact sham of interest? If owned with someone other than spouse,
-� - rl irate with whom:
❑Yes ❑No ��.{��
If name on record is different than that of applicant.indicate below.
Name of contract seller
Address of contract seller(number and street,oily,state,and ZIP cede) Is the property in question
❑ Real Propeaty ❑ MnuatyAssessed
Mobde Bane(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 gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes LgNo ')Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
Yes 0 N El Yes MNo
Toxin Istria Key number/Legal description Record number Page number
ab-act-)o-/0O-Qa03A5Oaj
1NVe ertify 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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Signature d auth - representative Address of authorized representative (number and stoat,city,star,and ZIP code)