HomeMy WebLinkAboutDisabilty_Reel (2) ts:41R--..1.4., APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
5e»!1. DEDUCTION FROM ASSESSED VALUATION IIR
=-=' State Form 43710(R9 r 9-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL : :s - M
pursuant to IC 6-1.1-12-12(b).
STRUCTIONS:
titiled in person or by mad with the CountyAUddor of the county where the property is boated.
Dates: f) Real Property.During the year for which the deduction is sought Jul 1 2014
2) Mobile Homes assessed under id IC 6l1.1-7 or Manufactured Homes not assessed as Real Property:Dunn the months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications- n IB S ON COu
Name f:,75nt(owner o r) ^ TYAUDITOR
U�)(J �/f 4///
AZ
Is applicant sole legal or equitable owner? If No,what is Mather exact sham of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
If name on recad is different than that of applicant,Indicate below
Name of muaa suer
Address of mntraa seller(number and street coy,state,and ZIP code) Is property in question
Real Property ❑ AnnualyAssessed
Motile 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)?
1:1 yes El No 10 yes 0 N
Fs the property used end occupied primadlyy for his/he residence? exceed Si 00?
❑Yes 0 N ❑Yes El No
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Key number/Legal description Record number Page number
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1,20 .
Signature of applicant Address of applicant (number and street city,state,and ZIP code)
I V..• D,! t7a21. Si Moro ?f,i Z V?eta
~ eudmr'¢ed representative Address of authorized representative (number and street city,slate,and ZIPcode)