Disabilty_Barron APPLICATION FOR BLIND OR DISABLED PERSON'S ` 41 L.4∎1 F7ilc. YEAR
;. DEDUCTION FROM ASSESSED VALUATION
" State Form 43710(R12/10-16) i . �■ -„Ill
•C'lif,F, Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. U L I F`ile'Mark
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 Properly.Form must be completed and signed by December 31 and filed or postmarked bXr I bO `V anuay3.o R
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Re -eDD nab the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Nameofof applicant ppt(owner or con uyer)
Is applicant the sole legal or eq>;mbl- .....: _ - 1.:.store of interest? If owned with someone other than spouse,
• �— indicate with whom
❑Yes 0 N
If name on record is different than that of applicant indicate below:
Name of contract seam
Address of contract seller(number and street,city,state,and LP code) Is the property in question:
❑ Real Property ❑ AnnuallyAssessed
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 activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No .Eel'es ❑No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
Yes ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
a6 - i3-do -roc - coo. .155_
I/We certify under penally of perjury that the above and foregoing information is true and correct.
Signature of.'..'nt Address of applicant (number and street,city,state,and ZIP code)
/i
gna�.�_� ealhonfred representative Address of authorized representative (number and street,call:state,and ZIP code) /