Disabilty_Henson z APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
6 State Form43710(R12I10-16)u,. Prescnbed by the Department of Local Government Finance G l `� I r �"V` "Ok el
.
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark 1
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the properly is located. -
Filing Dates: 1) Real Property:Form 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.
N- .. . applcan ... .. contract buyer)
valid ? I FVnVkacCT Hellion
.rm.- . - ..- ., PI .•unable owner? If No,what is his/her exact share of interest? If awned with someone other than spouse,
Lces ❑No Firamd..
�,)
If name on record is different than d�at�a� o�a�� pplirant indicate below:
JUN052019
Name of contract seller Jn/
r�—
Address of contract seller(number and street city,state,and ZIP code) 011330 N y N peropi Tar
. Real Rupaty ❑ Annually Assessed
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 Yes ❑No
Is the property used and occupied primarily for hEcoess
idence? Does the applicant's taxable gross income for car roll calendar year
Ni'es
exceed S17,000?
❑Noes ❑No
Taxing district Key number l Legal description Record number(°�Y...y1(, Page number(contact)
-e,r124-0\ . Ali-- 19-19 103-o 01 .2v1\-Ora.
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signal of applicant Address of applicant (number and street,shy state,and ZIP code)
Signature of authorized representative Address of authorized representative (number and street city state,and ZIP code)