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APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
1 DEDUCTION FROM ASSESSED VALUATION FILED
• State Farm 43710(R9/9-08)
Prescribed by the Department ot Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). CE LS 2 L 4 CU I" I adcn 17
INSTRUCTIONS: r
To be filed in person or by mail with the County Auditor of the county where the properly is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought —A MIN(
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real ope f es tf•n•,writ,: „ •,Afore
March 31 of each year the individ al wishes to obtain the deduction. lvi
See reverse side for additional instructions and qualifi tions.
Name of a (owner or contract buyer)
2. 1
Ls applicant the sole legal or equitable owne If No,what is higher exact share of interest? If owned with someone Star than sparse.
indicate 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,city,state,and ZIP code) Is the property 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 gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes t>t<so $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?
ZYes ID No ❑Yes %No
Taxi •. ttcl Key number/Legal description Record number Page number
' / ,e_ ! --I - 66-060.6,9-0027
I/We certify under penalty f 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 .
app scant Address of applicant (comber and street,city,state,and ZIP code)
de /80' eE x /D/7U/. jsdA/
Signature o(auNaraed representative Add of /representative (number sheet city,slate, /
67'71