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"'°'" APPLICATION FOR BLIND OR DISABLED PERSON'S COU►n
rti -� DEDUCTION FROM ASSESSED VALUATION
Siate Form a3770 (R / 9-96)
S,��� ? Prescnbed by Ihe State Board of Tat Commissioners
�.��rmation coniained in this document is CONFIDENTIAL pursuant ro IC 12-7-1-7(n) and IC 6-1.1-72-72(b). i
INSTRUCTIONS FOR FILING: �
To be liled in person or by mail with the County Auditor of the counry where the property is loca-
ted during the 72 months belore May 71 of the year the deduction is to be eflective.
See reverse side (or additional inst�uctions and qualifications. �.
p�nt (owne�
�// 1✓ `Pi
the sole leaal or
�Yes ❑ No �
If name on record is diNerent than at of applicant, indicate below
Name of contraa seller
�
Address ot coniract seiler
Is applicant blind as defined in IC 12-1-1-t(n) and IC 6-1.7-12-72�t
❑ Yes �No
used and occupied pnmarily for is/her residence?
� Yes ❑ No
Key number,
� � _.n
exad
TOWNSHIP I YEAR
i 1 �
1 ,
� ��✓
t�AY 0 7 1999
��c.���. . ,� . ,� , � �Q� �i_ . .
ClBSO"' ': . . 7
i someone other ihan spouse.
whom
I and unable to engage i a y substantial gainful activiry
i-i2�d�' �Yes ❑No
taxable gross income tor the preceding calendar year
❑ Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 79 �
�ature of applicant ^ Signature oi authorized representative (by executed Power ofAttomey)
represeniative
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