Disabilty_Woods APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY tTP
DEDUCTION FROM ASSESSED VALUATION ti �)
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State Form 43710(R9 1 9.08)
Prescribed by the Department of Local Government Finance ��{{ryl��,M
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). IYl7 P'ar1 2016
INSTRUCTIONS: ,
To be filed in person or by mail with the CountyAuditor of the county where the properly 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 Property:94V+ ingtePb@1lgl
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of app&ant(owner or contract buyer)
Is applicant the sole legal or equitable own4! If No,what is his/her e ct share of interest? If owned with someone other than spouse,
indicate with whom:
Wes ❑No
If name on record is different than that of applicant,indicate below:
Name of contract seller
•
Address of contact seller(number and street,city,slate,and ZIP code) Is a property in question:
Real Property ❑ Annually Assessed
Mobile Hate(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)? fyI
❑Yes ❑No Ej 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
rr� exceed 517,000?
YRr l res" ❑No ❑yes ❑No
2
Taxing distant Key number I Legal description Record number Page number ifr)
•
•._.1..rn :a 1- 26 - a, - 1?- lol-i••• - -0 :
IfWe certify under pen 4y 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) /
�I'!{//1 W )V ) gals £ 6; y0 /XOoLd ,f 2./titht V7&Yd
Sgnature of authorized rep entative dress of authorized representative (number and street,city,gate,and ZIP code)