Disabilty_Dike r--
e n4, APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY y TOWNSHIP YEAR
�' DEDUCTION FROM ASSESSED VALUATION a
_ djfrg State Form 43710(R12/10-16) (6.9)the
,o'r "d Prescribed by the Department of Local Government Finance Sit 201 g
file
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) VAL ,
(lila/Oak �JWte
'`� 77 o�Q
is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If o+nm� rtre other than spouse,
indica t om:
Yes El No , -cGR
If name on record is different than t of applicant,indicate below: OUIA-r( p.1.)
N
C
GIBS...,
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) property in question:
Reaf 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 ❑No \IYes El No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the r eding calendar year
exceed$17,000?
Yes ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
Die,osiktie. gt...17-0)-4112,3-OD-22g-D2.2.. ' '
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
ignature of applicant 4 . . . Address of applicant (number and street,city state,and ZIP code)
gVe4Mt
1
Signat of authorized representative Address of authorized representative (number and street city,state,and ZIP code)
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