Disabilty_Kelley • •p-.• APPLICATION FOR BLIND OR DISABLED PERSON'S cou t C. •j• ;a,,;;
DEDUCTION FROM ASSESSED VALUATION
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',.,�.., • State Fcan 43710(R9/9-08)
Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). - '
INSTRUCTIONS: ///��� ee.
To be filed in person or by mail with the County Auditor of the county where the property is located. l0'�"'
Filing Dates: 1) Real Property:During the year for which the deduction is sought. ����II�//����,1 t�n���,ITy f1�T/1R
2) Mobile Homes assessed under IC 6-I.1-7 or Manufactured Homes not assessed as Real Propt MQt$RrtffreHCe(? dfrWS'bAfae
March 31 of each year the individual wishes to obtain the deduction.
See reverse de for additional instructions and qualifications.
Name ofap (owner orconhaatbu
6rJ y \ ���
Is licant the site legs equ e eR If No,what is hisrher exact share of interest? If owned with someone other than spouse,
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,dry,state,and ZIP code) Is the property in question:
❑ Real Ptoperty ❑ Annually Assessed
Mobie 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 subs I gainful activity
as defined in IC 6-1.1-12-11(d)?
❑yes ❑No es ❑No
Is the property used and occupied primarily for hislher residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000? ,
❑yes ❑No ❑yes ❑No
Tax-•• `.tip Key number I Legal description Record number Page number
(�Lv/ix/.I/Ix .�(0-/7-/a-go 3 - 3 oala
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 sheet,city,state,and ZIP code)
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Signature of authorized represent rv9 C/ Address of authorized representative (number and street,city,state,and ZIP code)