HomeMy WebLinkAboutDisabilty_Hogg APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 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 postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly:During 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. FILED
Name of applicant(owner or contract buyer)
jirdp ,c) • • APR I 8.201R
Is applicant the sole legal or equitable owner? If No, rs his/her exact share of interest? If owned ywryith someone other than spouse,
indzate7v/ry�
❑Yes ❑No
W/I
If name on record is different than that of applicant,indicate below. ' ' ' AUDI TOR
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) Is the property in quesfion:
f27Real Property ❑ Annually Assessed
Mobile Home(IC 61.1-7)
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 aYes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes El:No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Z�-/a - , Jc13 - Go ! z2 9- 0Z
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)
\ale //03 ✓,UL jfltd Yi &J 4'7671
Signature of authorized representative Address of authorized re' ntatNe (number and street,city,state,and ZIP code)