Disabilty_Boyle e- .F APPLICATION FOR BLIND OR DISABLED PERSON'S couNTy it YEAR
DEDUCTION FROM ASSESSED VALUATION 1-4 IL
State Form 43710(R9/9-0E0
Prescribed by the Department of Loral Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). MAY 0 2 21114 Marx
INSTRUCTIONS:
To be filed in person or by mall 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 !!]]utt
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as RgatP® tXe (rclmonths before
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)
Is applicant the sole legal or equitable owner? If No,what is hislher exact share of interest? If owned with someone other than spouse,
indicate with when:
❑Yes No
If name on record Is different than that of applicant indicate below.
Name ui contract seller
Address of contact seller(number and street city,state,and ZIP code) Is the property in question:
❑ Real Property ❑ AnnuallyAssessed
Mobile Home(IC 61.1-7)
Is applicant blind as defined in IC 12-7-2.21(1)? Is applicant disabled and unable to engage it any substanfal gainful activity
as defined In IC 6-1.1-12-11(d)?
❑Yes ❑No {Yes ❑No
Is the property used end occupied primarily for hishar residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
51 Yes ❑No ❑Yes ❑No
Taxing Key number I Legal description Retard number Page number
w2140-IA -01 - o3-ood.�go .o.1V
liWe 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 appeeard (number street ,stale,and ZIP code)
t
Signature of authorized representative Address of authorized representative (number and street city,state,and ZIP code)