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�"°" APPLICATION FOR BLIND OR DISABLED PERSON'S courrrv TOWNSHIP vEna
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rti � DEDUCTION FROM ASSESSED VALUATION (/��� 0
State Fortn 43710 (R / 9-96) ��/�
S ; `r .
�,� Prescnbed by Ihe State Board of Tax Commissioners v O
File.Ma�k
Information coniained in this document is CONFIDENTIAL pursuant ro IC 72-t-7-7(n) and IC 6-1.7-12-12(b). a�' ;��� .�--;. �;�
INS7RUCTIONS FOR FILING �•' � �� .: �}!3 ��
To be filed in person cr by mail with the County Auditor ol the county where the property is lora- '�� "�"� �
ted during the 12 months be(ore May i l of the year the deduction is to be el/ective. i �"�Y I Q 2QQQ
See �everse side lor additional instructions and qualifications.
Name of applicant (owner or conhact buyer) n / / � n n
I�icant ine go�e iegai or
L
If name on record is diHeren
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Name of contract seller
Is applicant blind as
❑ Yes �No
7-7-
❑ Yes �No
the property used and occupied primarily for his/her
' '�Yes ❑No
_��_�� _ �a/- 00 3,
^�J���; 4' �:; l,^,ITOn^ �
I with someone other than spouse,
with whom
7.1-12-72(b)? Is appliCant tlisabletl antl unable [o engage fn any substanifal gafniul aGtivif
as defined in IC 61.1-12(d)? �Yes ❑ No
�esidence? Does the applicanYs t�abie gross income for the preceding calendar year
exceed $17,000? y
11f�Ylc iiti:G lnvr.�n�o ❑Y2S �No
Key number /
VW `` �I U� I i` O I I
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, 19 �
�ature of applicant _ Signature of authorized representative (by execured Power o/Attomey)
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of authorized representative