Disabilty_Miskell ate APPLICATION FOR BLIND OR DISABLED PERSON'SNT� oSHIP YEAR
fitii. DEDUCTION FROM ASSESSED VALUATION J1 g 1 J
2 - 14' State Form 43710(R12/10-16)
S ! Prescribed by the Department of Local Government Finance
"O MAY 9 2319
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. FII2 Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or t0(fjpJfitf(o Qry 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)n
/ ✓ '
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
Ifn a on record is different than that of applicant,indicate below:Lynda. Seerr-�,P a, ,x?4-d le- cry mis �9, didn 3CJ a.
Name of contact seller
Address of contact seller(number and street,City,state,and ZIP code) Is the property in question:
C Real Plowty ❑ 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)?
❑Yes ❑No gYes ❑No
Is the property used and occupied pdmanly for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes ❑No
Taxing dls d Key number/Legal description Record number(contract) Page number(contract)
tvn d &-do-/3 - /00 - coo- fa- Y- ooi
l/we certify under penalty of perjury that the above and foregoing information is true and correct.
Signatu applicant Address of applicant (number and street,City,state,and ZIP code)
k' it Aide/ Alit S,/Do C. alp/wnitCr4 y7tiE0
ignature of authorized representative Address of authorized re tative (number and street,City state, nd ZIP code)