HomeMy WebLinkAboutDisabilty_Bloodworth APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
-• DEDUCTION FROM ASSESSED VALUATION
State Fam 43710(R9/9-O8)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). F I L Ee)
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. � [[[[pp��qq �n�t�77
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Faopeachir$t144$eNe(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. • -
Name of (owner a contract buyer) �(��}}
indicate with whom
1 [Yes ❑No
If name on record is different than that of applicant,indicate below.
Name of contract�gr .
a
Address of contract seller(number and street.city,state,and ZIP code) Is the properly in question:
❑ Real Property ❑ MnuafyAssessed
Mobile Hare(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 I"No Io-lj -aolq bi Yes 0 N
Is the property used and occupied primarlfy for hisher residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 317,000?
]Yes 0 N CI Yes N''No
Taxing district Key number/Legal description Record number Page number
�Joh(son a (0_ 3- Ia3oo-coo• 1lc oat'
I/We 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)
f
ignatu I authorized representative Address of authorized representative (number and street city,state,and ZIP code) •