HomeMy WebLinkAboutDisabilty_Leukhardt APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Fonn 43710(R12/10-16)
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.
FrTrng Dates: 1) Real Property:Fomr 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 Propel.. ring the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction. LEDSee reverse side for additional instructions and qualificationsName of applicant(owner or contact buyer)
,airr L peal ?Qt�a Is applicant the sole or equitable owner? If No,what is his/her exact share of interest? If own-'Ail, someone o n spouse,
G ica. :1, whin=
'Yes ❑NoCN Co!/NTi':
If name on record is different than that of applicant,indicate below )'
'IL,c1?OR
•
Name oftx> seater
Address of contract seller(number and street,city,state,and ZIP code) Is the property� in question:
• tfrHeal Plow ty ❑ AnnualyAssessed
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 Lu.ATo ❑Yes ❑No
Ls 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?
LLYes ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
-. 1—C-11\0 4-., Q''. Q \9—l9 —Io I —t oD O a\p
Me 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)
k Aa0, this /,I i k�o,3 e to )4724 3t. rezA(44r /4,Yf
Signature f autt ed representative Address of authorized representative berand street,city,state,and ZIP code)