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Disabilty_Jenkins APPLICATION FOR BLIND OR DISABLED PERSON'S YEAR "_` DEDUCTION FROM ASSESSED VALUATION FILED , State Fonn 43710(R12/10.16) S t Prescribed by the Department of Local Government Finance 22❑❑�g8� Information contained in this document is CONFIDENTIAL pursuant to IC 6-11-35-9. MAY 9 FHe wlark INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located. • __L....4 Filing Dates: 1) Real Properly Form must be completed and signed by December 31 and filed or postmarked.. %1r- f% G Grpp 2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as RU)f!% -' . Ali{IIg Utz &? 7ve 1 )months before March 31 of each year the individual wishes to obtain the deduction. See reverse side for additional instructions and qualifications. IName of applicant(owner or contract buyer) is applicant the sole I or equitable own If No,what is his/her exact share of interest? - If owned with someone other than spouse, indicate with whore Al Yes ❑No it name on record is different than that of applicant,indicate below. Name of contract saw Address of contract seller(number and street,city,state,and ZIP code) Is the property in question; S eal Property ❑ AnnualyAssessed 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 ❑No es ❑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 ❑No Taxing district Key number!Legal description Record number(contract) Page number(centred) a6-/ 7-Os/- yoo- ooi. 73s _ oat . WJe certify under penalty of perjury that the above and foregoing information is true and correct. Sxinature of applicant Tess of applicant (number and street,city,state,and ZIP code) �\// A O./QeY'S!Y nano AA pr errA 9G/51-4/ • io S O W en-5'0ZZ c - n/ It 7&Ct to - Address representative Address of authorized representative (number and street,city state,and ZIP code)