Disabilty_Bruce � n APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
:e' =;. DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R12/10-16)
C -, Prescribed by the Department of Lod 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. rr
Ong Dates: 1) Real Property Form must be completed and signed by December 31 and filed or postmark y eg owi n!-
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real P rt DUtia4 -1 12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional inslnictions and qualifications. FEB 1 3 ants
Name of appfmant(owner or contract buyer)
kjer 1y w et uC-
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If 1 :. bt i %1�..- 6bd�f?-Mtif3
LW1res ❑No
If name on record is different than that of applicant,indicate below:
Name of contract seller
K.cdney /inichblify A f ruet)
Address of contact
seller(number andan street,city,state,and ZIP code) //'�� T//` / ' ,� Is the pi openly in question:
�t�f IP /�ID D- ), IMI6 / 11V yTLF(P"U ❑ Real Picr(,raty ❑ AnnualAssessed
MobileH (IC6-1.1-7)
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)?
ez.
❑Yes No BYes ❑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? �
ig
Yes ❑No Or ❑No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
Oa-Icb rid 26 1y 11-Boa —W I.207 a7
UWe 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)
w. q i. 11 be.s�Dr; v e- OatIaNd c, -y,, Y7LC
nature uthorized representative Address of authorized representative (number and street,aiy,state,and ZIP code)