Disabilty_Sherman • j. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
id .>, '1;= DEDUCTION FROM ASSESSED VALUATION
C- - State Form 43710(R9/9-09)
d`=
' r Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). �File2Me
1
INSTRUCTIONS: JUL UU
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. I et
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:k d .---—fir" before
Prof rty 1,�? 'Q
March 31 of each year the individual wishes to obtain the deduction. COUNTY
See reverse side for additional instructions and qualifications. GtBSON
Name of applicant(owner or contract buyer)
Ri \--... 7 . , , )
Is applicant the sole legal or equitable owner? If No,what is tastier exact share of interest? if wined with someone other than spouse,
indicate with whont
oyes ❑No
If name on record is different n that of applicant indicate below:
Name of contract scaler
Address of contract seller(number and street,city,state,and ZIP code) Is p e properly in question:
Real Property ❑ Annually Assessed
Mobile Harie 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 la es ❑No
Do
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for th preceding calendar year
exceed 517,000?
Eases ❑No ❑Yes No
Taxing district — Key number/Legal description Record number Page number
. ez al'(- 076.-c&_19/v/ axe/ ?°/ 9
I/We ce fy 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) II 14 .7 4 y 0
2C- �. if AI N leAsrvesscc T OA2.QlTotel 1 S)
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)