Disabilty_Singleton APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
;Y -;. DEDUCTION FROM ASSESSED VALUATION g �(L D
-.."-` s State Fonn 43710(R12/10.16) �^ 1
°"- 1 Prescribed by the Department of Loral Government Finance
m
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. APR 1 7 2018 File 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 Property:Form must be completed and signed by December 31 and filed or postm g January 5
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assess !go Lt1 ,tyirt�fretiv(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of plicant(owner or contract buyer) /J �I
C � /E I
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? - If owned with someone other than spouse,
indicate with whores
❑Yes ❑No
If name on record is different than that of applicant,indicate below.
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
-Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Is applicant bfmd 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 ❑Yes ❑No
Is the property used and occupied primanly 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(contract) Page number(contract)
r
AG-)3-3 y - 200 - OO (, a 79 _o0 6
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
u authorized ,, �' �u1 a 1 v o n S 07frz 0 c, W ),�
'Sigma of rr p� Address of authorized representative (number and street,city state,and ZIP code)
y76___‘xd