Disabilty_Crowley APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
j1 DEDUCTION FROM ASSESSED VALUATION
- State Form 43710(R9/9-08) ��
_ Prescribed by the Department d Local Government Fnarla Ii a
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File'Va ' 4 li
INSTRUCTIONS: AUG 8 2017
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 sough
2) Mobile Homes assessed under IC St 1-7 or Manufactured Homes not assessed as Real Property During rl�/wel(e rr bsbefora
March 31 of each year the individual wishes to obtain the deduction. IBSONJO^(�{
See reverse side for additional instructions and qualifications. '-OUNTY AUDITOR
t.
Name of applicant(owner or contract buyer)
•
Is applicant the sole legal or equitable owner/ 0.what is his/her exact s f interest? If owned with someone other than spouse.
indicate with whom:
❑Yes E]No
If name on record is different than that of applicant,indicate below:
Name of contract seller
Address Cl contract seller(number and sheet,oily,state,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-L1-7)
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)?
El Yes [aio I{Yes 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 S17,000?
Yes ❑No ❑Yes ]No
Taxing district Key number/Legal description Record number Page number
l!/d� a lo-Vg" o7 /0/ 0 00 O O oa 0)
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 .
'•nat re of applicant Address of applicant (number and street,city,stare,and ZIP code)
ii On i 411 fii
Signature of auNOr¢ represen alive / Address of authorized representative (number and street,city,state,and ZIP code)-