Disabilty_Byrne�t
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r• APPLICATION FOR BLIND OR _
a`'���'�0,� DISABLED PERSON'S DEDUCTION
_� . , FROM ASSESSED VALUATION
�.'• ,.,� ,,'i State Form 43710(1-90)
Prescribed by the State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
Applicant (Owner or contract buyer)
Is applica the sole legal or If what is his/he
eqwtab owner? int rest?
yes � no
If name on record different than that of applicant, indic
Name of contract seller:
Address of contract seller:
Is applicant blind as defined in IC 12-1-1-1(n) &
IC 6-1.1-12-12(b)?
� yes � no
Is the pr erty used and occupied primarily for his/her
reside ce? �
yes � no
County � Township
MAY O 1 1996
Year
� �� ��
AUDi��R
than
spouse, indicate with whom.
Is the ap icant disabled and unable to engage in any
subst tial gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Does the applicanYs
preceding calendar
� yes ��
Key Number/Legal Description
ble gross income for the
exceed $13,000?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicar.t
was a resident of Indiana and owner of the aforementioned property on March t, 19 .
Signature
Authorized Representative (by executed Power of
Attorney)
Address of Representative