HomeMy WebLinkAboutDisabilty_Davis (4) .- APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
=$';_ DEDUCTION FROM ASSESSED VALUATION
t- a State Form 43710(R12/10-16)
S =%";* 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 County Auditor of the county where the property is located.
Filing Dates: 1) Real Properly Form must be completed and signed by December 31 and tiled or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly 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 applicant(owner or contract buyer)
r(11/42. .-10.-� 1 S Nov9
Is applicant the sate legal or equitable owner? If No,what is h islher exact share of interest? If owned with someone otff6r thaovouse,
indicate with sane we
Lu tes ❑No SCryr
If name on record is different than that of applicant,indicate below. kJ4 ' •./
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Name of contract saber
Sabr C. S tTh mCC \ LC
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real Rowdy ❑ 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 agrd Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed S17.000?
al ❑No ID Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Pre\nCe.--;o.(Th a6—ll�la—Qoyoela71S- a2 .
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)
Signature of authorized re ntative Address of authorized representative (number and street,city,state,aird ZIP code)