HomeMy WebLinkAboutDisabilty_Michel (3) •
/* • ' s
s
0, q. APPLICATION FOR BLIND OR DISABLED PERSONS COUNTY TOWNSHIP YEAR
a �; DEDUCTION FROM ASSESSED VALUATION
N1' State Form 43710(R/9-96)
. Prescribed by the State Board of Tax Commissioners a
mie
drrhation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n)and IC 6-1.1-12-12(b). FI ar
INSTRUCTIONS FOR FILING: Y
To be filed in person Cr by mail with the County Auditor of the county where the property is loca-
ted during the 12 months before May 11 of the year the deduction is to be effective. 110
0
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
tcc3e44 - ) OO1d AUSI'(OR!/�711 /"0 - 1 /1:/7Z GIBBON
Is applicant the sol I al or equitable owner? I o,wha is hislher=exacf share of interest?. Ifnd ownedicatewith who with someone other than spouse,
m
Ca'�'es ❑No e4
If name on record is different than that of applicant,indicate below
Name of contract seller
Address of contract seller
Is applicant blind as defined in IC 12-1-1-1(n)and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any substantial gainfulactivity
as defined in IC 6-1.1-12(d)? ❑Yes 2IVo
❑Yes [ l'I 6Q d
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?
es ❑No ❑Yes RNo
•
axing is rict Key number/Legal description Record number Page number
;�� �/ e :e5/-moo
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 -
Signature of applicant Signature of authorized representative(by executed Power of Attorney)
..e... . ...:"j
XAddre of applicant , ' Address of authorized representative