Disabilty_Harvey APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION COUNTY TOWNSHIP YEAR
State Form 43710(R12/1016) n I �' I21/ 1
Prescribed by the Department of Local Government Finance l` qt,� ,Vc{,,V.FI`,.�„� V
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. N't File Maf c�/�p
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:Foram 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 Properly: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)
— - • - L 44,r-vet_i 4FJLJ
Is applicant the sole legal or equitable owner? If N ,what is his/her exact share of interest? If owne an spouse,
indicate with whom:
s 0 No FEB 3 2020
If name on record is different than that of applicant,indicate below: 00
Name of contractselier G1E—ON COUNTY A' OR
•
Address of contract seller(number and street;city,state,and ZIP code) Is property in question:
eal 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 Jo \/..y,2j
El 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?
yes ❑No ❑Yes ❑No
Taxing district Key number/Legal description Record number(contract) Page number(contract)
I� er 2(—/0 • 25 -200 • moo - 0a!
I/We certify under penalty erjury that the above and foregoing information is true and correct.
Signatur- : a.plicant Address of applicant (number and street,city,state,and ZIP code)
2-9.99 L115 T OtOeNk&
Signatu e of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
.BPfectett. 'Please"let us KrioW lI you t 11[C11gC yuui rttauusg auw Coo, vvv
can send you letters directly.
• The day of the month you receive your payments depends on your date
of birth.
Enclosure(s): `
Pub 05-10153
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