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,, ICATION FOR BLIND OR DISABLE ERSON'S COUNTY TOWNSHIP YEAR
-�� _ EDUCTION FROM ASSESSED VALUATION
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;Y: Spate Form 43710(R12/10-16) ��,^ n ^ O
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f1e 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 elv (12) onths before
March 31 of each year the individual wishes to obtain the deduction. \_ R -Ssi
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See reverse side for additional instructions and qualifications. \\
Name of applicant(o rorcorntra�ctbuye � t1
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tIV
V) .
Is applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
ices ❑No �� ... . .'�'
If name on record is different than a f applicant,indicate belo . I.e Vi` �1 ...
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APR1%V
Name of contract seller
Address of contract seller(number and street,city,state,and ZIP code) OU14'(Y P`��,�O� Is perry in question:
GOSON G 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 a age in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes X-.), res
❑No
Is the property used and occupied primarily for hiidence? Does the applicant's taxable gross income forthing calendar year
exceed$17,000?
❑Yes ❑No Yes ❑No
Taxing district Key number 7 Legal description Record number(A
t) Page number(contract)
a-02�O$ '26 -00 1 . .s.1 -O Zg
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
KAddrSignature of applicant
ess of applicant (number and street,city state,a d ZIP code
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S nature of authorized representative Address of authorized representative (numbe s et,city,state,and ZIP code)