Disabilty_Trotter -_ 3. ; APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
Farm State Fm 43710(Rg FROM PI ED
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). d
INSTRUCTIONS: SEP 5 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 Properly: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 Propenrg th ve )-uwnths before
March 31 of each year the individual wishes to obtain the deduction. G.(BSQN C
See reverse side for additional instructions and qualifications. AUNTY gl1DITQP
Name of a()' tf(owner or ccoontract buyer)
ri//.u7J or equitable air r7 /
(da I' m the sd��.•{{egal or equitable owner `No,what is his/her enact 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 contrail seller
Address of cmnbad seller(number and street,clay,state,and ZIP code) Is property in question:
Real Property ❑ Annually Assessed
Motile Horne(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 ial gainful activity
as defined in IC 6-1.1-12-11(d)?
Dyes ❑No Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for t preceding calendar year
exceed$17,000?
Dyes ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number Page number
A1- Af-3G-eito - oo„i . o oaV
IIWe 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)
Signature,authanzed'repre� Address of authorized representative (number and street,city,state,and ZIP code)