Disabilty_Paul 1
s • APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
' ° �};- DEDUCTION FROM ASSESSED VALUATION
Sr
State Fo (epat
5�==I Prescribed by the Department of _
Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 'e M•1'
INSTRUCTIONS: �k
To be filed in person or by mail with the County Auditor of the county where the property is located. 1
Filing Dates: 1) Real Property.Form must be completed and signed by December 31 and filed or posth `/I'-following J 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Pri '.. 'ng the twe 12)months before
March 31 of each year the individual wishes to obtain the deduction. p !j
See reverse side for additional instructions and qualifications �41,- i,''-
Name of applicant(owner or contract buyer) 44/0 �� I
.Q• ►d f r?a_A,L_ TAR
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 whom
L&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 question:
❑ Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
le applicant band 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)?
W'4es ❑No ❑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?
IUIs No ❑Yes ❑No
Taring district Key number/Legal description Record number(contract) Page number(contract)
r\ce_�-OCN cU- -Oko-\-1Q3- C ) Lk
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) L\-111
,40
Xy At Pitr'r-c.ot��t ,Pr nc..e_JOnL
S' a of authorized representative Address of authorized representative (number and street,city:state,and ZIP code)