HomeMy WebLinkAboutDisabilty_Fetcher . • APPLICATION FOR BLIND OR DISABLED PERSON'PERSONt T p ,t, u Y TOWNSHIP YEAR
- DEDUCTION FROM ASSESSED VALUATION
S?�t" 's State Form 43710(R12/10-16) F.
A ¢-
S., Prescribed by the Department of Loral Government Finance
NOV 8 20MII File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is lore p
Filing Dates: 1) Real Property:Form must be completed and signed by Decembers l .g frotjdcg yit lowing January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes no assess=•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 applicant(owner or contract buyer)
1.1
Is appdcan[the legal or egxnfa a owner? If No,what is hssmer exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
If name on record is different than that of applicant,indicate below:
Name of conbad seder
Address of contract seller(number and street,city,state,and ZIP code) i,s the property in question:
L. al Property ❑ Annually Assessed
,,v Mobile Home(IC 6-1.1-7)
Is applicant bind 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 NESs ❑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?
rs ❑No ❑Yes g .
Taxing district Key number/Legal desolation Record number(contract) P e number(contract)
0.
0k1 A/we!) Z1r-02 -S?-o1Ss- ooa.z91,-0t i'
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of ap nt Address of applicant (number and street,city.state,and ZIP code)
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Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)