Disabilty_Tooley •
^". APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
k„ ,.t DEDUCTION FROM ASSESSED VALUATION
____"- State Form 43710(R12/10.16)
C i Prescnbed 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. 8le10e 1 ?
Filing Dates: 1) Real Property Form must be completed and signed by December 31 and filed or postmarked b ng ,
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes no assessed as Real Pro.•':`p. -tt'. th (12)months before
March 31 of each year the individual wishes too tan the deduction. I tIF 1 9
See reverse side for additional instructions and qualifications. 1.6
6. V
Name of applicant(owner or contract buyer) ix?R
7(3e-INN Sr - -Took e_ ( PovccoR
Is applicant the sole legal or equitable owner? If No,wt, his/her exact share of interest? • If owned with N 'poise,
indicate with wtr�
Gib
Res ❑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 `ty in queston:
N I ^ LWRealProperty 0 AnnuallyAssessed
(� 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)?
❑YesO ❑Yes ❑No
Is the property used and oaupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
ale; ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
ast,KL t\c-}-Qf ag0- Dlci6O -ac3-coo . in - 0ti1
IfWe 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)
e 3 S .7-Il/4(74" Y
Signa .re of authorized representative �arress of��uthor z d representativeNr � i fed
-ate,and ZIP code)