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Disabilty_Nichols APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR Cic ,- DEDUCTION FROM ASSESSED VALUATION State Form 43710(R12/10-16) Prescribed by the Depattrand of Local Government Finance JGk Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark INSTRUCTIONS: OCT-9 2018 - To be filed in person or by mail with the County Auditor of the county where the property is located. - wng Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postmarked by the fo g J u 2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property months before March 31 of each year the individual wishes to obtain the deduction. G'Q - AftMl16fifb R See reverse side for additional instructions and qualifications. • Name of applicant(owner or contract buyer) b 10R) fat 3© KYtu is Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse, indicate with wham RI/Yes ❑No If name on record is different than that of applicant,indicate below Name of contract seller Address of contract serer(number and street city,state,and ZIP code) Is thezproperty in question: S Real Plopeiy ❑ AnnuallyAssessed 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 Vices ❑No Is the properly used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year '/ exceed$17,000? I.TJ Yes ❑No LN Yes ❑No Taming district Key number 1 Legal description b Record number(contract) Page number(contract) en12),M6 ia7111"(1—±y.6 a1 DDQ4&'OD77 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) • M Signature pl bYPo(1We DRIOand ) 4��ma of a -•= re resents' e Address of authorized re resen a (number street. state,and LP code