Disabilty_Koberstein (2) / X APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
\ter N DEDUCTION FROM ASSESSED VALUATIONL �
.. f;s
t::" l� State Form 43710(R12/10-16)
�,u/ Prescribed by the Department of Local Government Finance
I�abon contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. NOV 5 2018 File Mark
RUGTIONS:
To be Wed 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 lowing January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assaGIERSORPrit 6C1l97JR'Ckid rtef'elve(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 applicantict((ownern, or contract buyer) -
e
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 wl.AU.
❑Yes ❑No
If name on record is different than that of applicant indicate below:
Name of contract seller
•
Address of contract seller(number and street,city,state,and ZIP code) Is the property in quesfion:
❑ Real Property ❑ 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 6i1.1-12-11(d)?
❑Yes Ntho 171Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
® exceed$17,000?
Yes ❑No ❑Yes ❑No
Twin district
i Key number/Legal description a 6-fa -/ 8- at)/ - 00 .2. 7 go Record number(contract) Page number(contras)
- O?- 8
I/N/e certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant _J Address of applicant (number and street,city state,and ZIP code)
CAA r t, C LZ -_- .i X g i q 5 , v�A r .Nc ,1/4.) sue. 6-7D
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
0 K PC- . --