Disabilty_Reed :c1i.. APPLICATION UC OROM BLIND OR DISABLED PERSON'S r g YEAR
;;,- i;= DEDUCTION FROM ASSESSED VALUATION 1 g�j
: 2 Slate Form 43710(R9/9-O6)
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Prescribed by the Deportment of Local Government Finance 1 cc��NNqqp�,r
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). MAY 1 W410 "
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
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Filing Dates: 1) Real Property:During the year for which the deduction is sought. `jl./IW1�,l
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Reattnys r (fyaq(ths before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications-
Name Wjppf nt(owner or contract buyer)//f^r k I
Is applicant the site legal or equitable owner? If No.what is his/her exact share of interest? If owned with someone other than spouse,
indicate with ER? s ❑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'�ppro�op'''eM in question:
fProperty ❑ Annually Assessed
Mobile Horne(IC 61.1-7)
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 No El Yes ❑No
•
Is the property used and occupied primarily for hL4her residence? Does the applicants taxable gross income for the preceding calendar year
exceed 517,000?
Ot ( les ❑No Wes El No
Taxing _ _ / Key number/Legal description Record number Page number
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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)
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Signature of a onz representative Address of authorized representative (number and streetcity,safe,and ZIP code)