Disabilty_Ott N,en„v. APPLICATION FOR BLIND OR DISABLED PERSON'S e—Lrurv-iYY TOWNSHIP YEAR
31 `- ;4 DEDUCTION FROM ASSESSED VALUATION
x )' = State Form 43710(R12/10-16) 1 `W ' [�
`te/d �0 —I
+eye Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. ark
INSTRUCTIONS: �^
'lb be Ned In person or by mail with the County Auditor of the county where the property
�
Name applicant(owner or contra uyer)
el egy
Is applicant the sole legal or equitable owner? If o,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
es 0 No
If name on record is different than t f applicant,indicate below:
FILED
Name of contract seller
DEC 1:8 2019
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
0 a Real Property 0 AnnuallyAssessed
/�� ��[n� Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? G I B SO f`I s a pl cant mama and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes ❑No ►.'1 Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for .re,-ding calendar year
exceed$17,000?
Cl Yes ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
FNCLn 2 C -13-1q- Poo ^000 .51-3-00)—
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
9
'Signs re of applicant Address of applicant (number and street,city,state,and ZIP code)
zs..... ail._
5S-77 15-- &I- vt-clr CLI 1 17--yorkc4.1u:::).-- on •
Si ature of authorized representative Address of authorized representative (number and street,city,stateland ZIP code) 976 r/1