Disabilty_Morgan APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY min
P- DEDUCTION FROM ASSESSED VALUATION
'_ State Form 43710(8919-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). Fil 'fnQ 9 2011
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.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:aar+S6)ldv@O 11o�r)t(hybifft3R
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
m �Is applicant u owner? I ,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
•
es ❑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,state,and ZIP code) I the property in question:
eat 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 adnity
as defined in IC 6-1.1-12-11(d)?
El Yes 0 N trYes 0 N
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
Yes ❑No ❑Yes 'No
Taxing district \\ Key number I Legal desaiption Record number Page number
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 VP code)
YTAp,J. �i _ 327E 7955 Fort-BraYt.l Zv `f7b4S
na re of uthora resents ( 1 Address of authorized representative (number and street,city,slate,and ZIP code)