HomeMy WebLinkAboutDisabilty_Koberstein . APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
. Y DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. APR 2 3 2018
Filing Dates: 1) Real Property.Form must be completed and signed by December 31 and filed or postmarked by the following 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12 e(ae
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. COUNTY AUDITOR
Name of applicant(owner or contract buyer)
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bl applicant the sole legal or rable owner? I o, t is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
❑Yes 0 N
If name an 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 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 I' Jo CAYes
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?
'es ❑No ❑Yeso
Taxing-d�#s try/ _/ I Key number/Legal description Record number(contract) Page number(contract)
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I/We 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)
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Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
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