Disabilty_Phelps •
APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
1J DEDUCTION FROM ASSESSED VALUATION
•
State Form 43710(R9/9-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: �--�g
To be filed in person or by mail with the County Auditor of the county where the property is located. 1fglL�J 1p]i
Filing Dates: 1) Real Property:During the year for which the deduction is sought . 7
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
OCT 3 j Z
See reverse side for additional instructions and qualifications.
Name of applicant( contract buyer) p (����((11CC[[11 //////111111 h/�f r�t� ��',��.�
Is applicant the sole legal or equitable owner? If No,what is his/her ex interest? RLM'ASd Vn e°oth ericdacTAC'
indicate with whom:
❑yes ❑No
If name on record is di terent than that of apparent:indicate below:
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is the properly in question:
❑ Real Property ❑ Annually Assessed
Mobile Bane(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 inful activity
as defined in IC 6-1.1-12-11(d)?
❑yes ❑No es ❑No
Is the property used and occupied primarily for hisher residence? Does the applicant's taxable gross income for the preceding calendar y r
exceed$17,000?
❑yes ❑No ❑yes No
Taxing district Key number/Legal description Record number Page number
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UWe 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 steel,city,state,and ZIP )
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at•r=f a •one=_
rep- .n-'•e —�� Address of authorized representative (number and street city,state,and ZIP code)