Disabilty_Willis h ap., APPLICATION FOR BLIND OR DISABLED PERSON'S couNT CHIP YEAR
` :::._ DEDUCTION FROM ASSESSED VALUATION p$�/
State Form 43710(R12110-16)
Presaibed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. A Re 14*2018
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 postmarked by the follo a
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly)®&@�CD*6P' 1Y Y„616AtifeEifore
March 31 of each year the individual wishes to obtain the deduction. Y.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
I
W �1
Is applicant the sale legal or equitable aim 1"."2‘ If No, t is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
l Yes ❑No
If name on record is different than that of applicant,indicate below.
Name of contract seller •
Address of contract setter(number and street,city,state,and ZIP code) the property in question:
yB Real Property ❑ Annually Assessed
(( Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)7 Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No . 'e Yes ❑No
Is the property used and occupied primarily for his/her residence? Doe s the applicants taxable gross income for the preceding calendar year
exceed 517,000?
❑Yes ❑No ❑Yes ❑No
Taxing district Key number/Legal desrnption Record number(contract) Page number(contact)
Qom=e ms, �14 Df w - L . -o4 •1b0 —cx3. H (a-art
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 LP code)
J ,�f = te YN' N. SAofc br. Pr:�iciL4 �il . 17670
S nature of au representative Address of authorized representative (number and street,city,state,and ZIP code)