HomeMy WebLinkAboutDisabilty_Krug (2) �., , APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
:,1: DEDUCTION FROM ASSESSED VALUATION
State Form 43710(R12/10-16) //'�' 1^ 1 1
Prescribed by the Department of Local Government Finance '1 \\\ ~ .\ V 1 '� L
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. V File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Aud for of the county where the property is located.
Filing Dates: 1) Real Properly Fonn 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 applicant(owner or contract buyer) I� Q �
Icy. �Y — C �e'Xi2tci. ,
Is applicant thV a legal or equitable owner? If No/what is-his/her exact share of inteiet? If owned with someone other than spouse,
v
I
ikes ❑No ,C y,
If name on record is different than gist of'applicant,indicate below. - `— -'
DEC 1 2 2018
Name of contact seller
r IRSoN enhlitZJTY AI IMITOR
Address of contract seller(number and street,city,state,and ZIP code) Isit Cproperty in question:
0 Real Plowly ❑ AnnuallyAssessed
\ Mobile Home(IC 6-1.1-7)
Is applicant Mind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to?ngage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No l,( �Yes ❑No
Is the property used and occupied primarily for Wier residence? Does the applicant's taxable gross income for the pre ceding calendar year
exceed$17,000? /
❑Yes ❑No ❑Yes II No
Taxik�g dIL:.t l Key number 1 Legal description Record number(contract) Page// \umber(contract)
l lweAs\A lie %-VI- 0t kO4 -000.4SN- z .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant I Address of applicant (number and t,city,state,and ZIP code)
XC Wht 130s �a0 0 •A\1 �. on - � (-)
N a rdp 2
Sig�atu of a retfre'sentagve Address of authorized n:presienta' (number and sue)tf,city,state,and LP code)