HomeMy WebLinkAboutDisabilty_Good APPLICATION FOR ASSESSED SE DISABLED PERSON'S COUNTY To FaR
- ' ��`: DEDUCTION FROM ASSESSED VALUATION Y
6�-- State Form 43710(R12/10-16) J
1/4„:_!r-.;„ Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. MFt e U'ffk/Ulo
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 lotion j u ���rt� f�
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Propert}esrgQ NrOgil bi(Ti1)srrdmns Plana
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
4/' cAccel
Is applicant the sole legal or equitable owner 1 If No,what is hisher exact share of interest? If owned with someone other than spouse,
(/ indicate with whom
❑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:
I Real Property ❑ Annually Assessed
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 gNo Lames No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross incur-for the preceding calendar year
exceed$17,000?
,'es ❑No ❑Yes $No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
F -009°00. 70/-cc
INVe certify under penalty of prirjury 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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2 ���r /40:. '/ ' l06
Signature of authorized representative Address of authorized representative (numet and street,city state,and ZIP... •