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Home My WebLink AboutDisabilty_Kell (2) a� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR 3 . :- DEDUCTION FROM ASSESSED VALUATION State Form 43710(R12110-16) Si? Presented 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 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 following January 5. 2) Mobile Homes assessed under IC 6-1.1-7 or 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 aunt. I owner or contract buyer) \/\j�\�►� &iser Is applicanlegalouitabl e / /r If No exact share of interest? If owned with someone other than spouse. // indicate m icate with who LZYeC ❑No It name on record is different than that of ape/kart indicate below. Name of contract seller Address of contract seller(number and street city,state.and ZIP code) Is the operty in question: 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 ❑No a<e ❑No Is the property used and occupied primarily for hisihher residence? Does the applicants taxable gross income for the preceding calendar year exceed$17,000? ❑Yes ❑No ❑Yes B'No Taxing district Key number 1 Legal desatption Record number(contract) Page number(contract) a 6 - Z 4-I 8 -all.-ooa, as -D© 9 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) / Sig authorized/-• -:,p":tive Address of authorized representative (number and sheet city,state,and ZIP code)