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Disabilty_Quinn • - '. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR DEDUCTION FROM ASSESSED VALUATION `li' State Form 43710(R12/10-16) 1 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 poison or by mail with the County Auditor of the county where the property is located. T Tp g�,1 Filing Dates: 1) Real Property Form must be completed and signed by December 31 and filed or postmarked by th n lanuaT�S. 2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly: nng.the-(welveM(12)tutu s before March 31 of each year the individual wishes to obtain the deduction. -1 See reverse side for additional instructions and qualifications. S E P 1 9 2018 Name of applicant(owner or contract buyer) H applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned of teone'othis$ian spouse;'•T indicate with whom: EPes No If name on record is different than that of applicant indicate below: Name of contract seller • Address of conted d.affee;-city; e,as P ode) Is the p in question: D- ealProperty ❑ 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)? CI Yes iitt ❑Yes No Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar y exceed 517,000? C+}'Yes ❑No ❑Yes No Tatting district Key number I Legal description Record number(contract) Page number(contract) PryrNc Gaon �t9 la 1 c n -oCr2 .1494 -® 38. UWe 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) X z . Ibsdotm5X- . Signature of authorized representative Address of authorized representative (number and skeet,city:stale,and ZIP code)