HomeMy WebLinkAboutDisabilty_Pierrard • in�4/ APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
5t4, DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16)
C i 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 person or by mail with the CountyAuditor of the county where the property is located.
Fang Dates: 1) Real Property:Form must be completed and signed by December 31 and fried or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-I.1-7 of Manufactured Homes not assessed as Real Property During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of appfican r or contract buyer)
SIs applicant the sole legal or equitable ovine exact share of interest? If owned with someone other than spouse,
indicate with whhonc
NI-afg O No
If name on record is different than that of applicant,indicate below.
Name of contract seller '
Address of contract seller(number and steel,city,state,and ZIP code) Is the in question:
Real Plomly 0 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 substan• gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No Yes ❑No
Is the property used and occupied pdmarly for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑
[Me certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant �"_y� Address of applicant (number and street,city state,and ZIP code)
(Sgnahrre of authorized J. /representative Address of authorized representative (number and street city,state,and ZIP code)