HomeMy WebLinkAboutDisabilty_Lanman ADEDUCTIONPPLICATIONFROM FOR BLIND ORASSESSED DISABLVALUATIEDON PERSON'S
ag- COUNTY TOWNSHIP YEAR
State Form 43710(R12/10-16)
®�o Prescribed 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.
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.
Name of applicant(owner or contract buyer)
E . Lc Is applicant the s le I I or equitable owner? If No,what is his/her exact share of interest? . 1•wit -.411 per than spouse,
Yes ❑hlo 11°
If name on record is different than that of applicant,indicate below: O`1
Name of contract seller
•
pc(O
N1� PV �
G`eSO�Gov
Address of contract seller(number and street;city,state,and ZIP code) Is tthee p erty in question:
Ly'Real Property ❑ 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 ig'No LKYes ❑No
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 El No El Yes El No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Pr'.
I/We certify under pen.Ity of perjury that the above and foregoing information is true and correct.
Signat of applicant Address of applicant (number and street,city,state,and ZIP code)
" 0,La31
Signature of o presentative Address of authorizea representative (number and street,city,hate,and ZIP code)
Meaicare lntormauion
You are entitled to hospital insurance under Medicare beginning December
2016 .
You- are entitled to medical insurance under Medicare beginning September
2019 .
Your Medicare number is 7E14-H01-XU65 . You may use this number to get medica:
services while waiting for your Medicare card.
If you have any questions, please log into Medicare .gov, or call
1-800-MEDICARE (1-800-633-4227) .