HomeMy WebLinkAboutDisabilty_Dyer (2) e�� APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
ji -t DEDUCTION FROM ASSESSED VALUATION V
`'.. 4 z State Form 43710(R12/10-16) \ AA/0
„:D Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. /°
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)
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Is applicant the sole legal or esill
ble owne If No,what Is is/her exact sham of interest? If owned with someone other than spouse,
indicate with whom
Yes 0 No
If name on record is different tha that applicant,indicate below:
JUN 2 6 2020
Name of contract seller
Address of contract seller(number and street;city,state,and ZIP code) G I Iss eUgtViPtglYstigalig D ITOR
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 Yes ❑No
Is the property used and occupied primarily for is/h residence? Does the applicant's taxable gross income for the pre ding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes o
Taxing district 1 Key number/Legal description Record number(contract) PA
umber(contract)
ir) ),6\2-0 - `201-0, I.ctZs- 02-8 .
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
ignatu of applicant Address of applicant (number and street,city,state,an31\ode)
IffC10W �S `t ` � -3n�-Ll7 c,`
Si e o authorized presentative Address of authorized representative (number and street,city,state,and ZIP code)
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name of applicant o Date filed(month,day,year)
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Name of contract seller V )C11; Zo��
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Taxing district
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Key number/legal description rr�� C�` T n G18SON _
z6 — `2 — V1 `2,0\ — 0 01 .92 J -0 �-f� - COUNTYA(;n/ o.
Signature unty itor Date signed(month,day,year l?