Disabilty_Bruce APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION _ ///
State Form 43710(R72/10-16) q":1\r,J-r�i,.s 2-01 j ,Prescribed by the Department d Local Government Finance _V 1.IY•
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.
Filing Dates: 1) Real Property Form must be completed and signed by Dece r and filed or postmarked by the following January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Ho es t assessed as R�Twpetty:During the twelve(12)months before
March 31 of each year the in ' •. ' es to obtain the dedu on �J
See reverse side for additional insbvdi• s and qualifications. �'-l/_n`
Name of applicant ..._,
(owner or •Mb
.04, \,„.,, , .
Ls applicant the sole orl�equila rs r exact share of interest? If owned with someone other than spouse,
indicate with whorrc
Xes ❑No `
If name on record is different than t applicant.indicate below F ILE t,)
Name of contract setter JUL 2 3 1019
j
Address of contract seller(number and sheet,city,state,and ZIP code) HOT" OR Is party in question:
VBSCM4CO TY AUDIT Real Property ❑ Annually Assessed
+] \11 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 YG Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for ug calendar year
����//// exceed$17,000?
C)'es ❑No ❑YesAo
faxing district �' \` Key number/Legal description Record number(contract) umber(contract)
Cjj7kle‘ — C —l14-2o - t o o -vol-0i i -00 6
•
IlWe certify under penalty of perjury that the above and foregoing information is true and correct.
jnature of applicant Address of applicant (number and street,city,state,and ZIP code)
ka
l3 ) 6 'I C �,00 Sr ok� l (4"�j - Jn - un-6 ' D.
tu authorized rep n Address of authored representative (number and street,city,state,and ZIP code)