Disabilty_Lucas •
...4 APPLICATION FOR BLIND OR DISABLED PERSON'S ' . : '�WNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
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- State Form 43710(R12/10-16)
*s"'''e" Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. MAY 2� zO2 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 fpflptg January 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not j¢g$ �r� e .Dunng 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 ap nt(owner or contract uyer)
Is applicant the sole legal or equitable owne If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
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If name on record is different than that of applicant,indicate below:
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is the property in question:
0.Real Property 0 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 XYes 0 No
Is the property used and occupied primarily for ' /her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
%.Yes ❑No ❑Yes jeNo
Taxing district Key number/Legal description Record number(contract) Page number(contract)
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I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
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Signature of authorized representative Address of authorized representative (number and street,city,state,an code)
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71..-u / V '';. .
606 VETERANS DR
VINCENNES, IN 47591
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