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�� 4� APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
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�` f State Form 43710 (R7 / 5-06)
Presaibcd by U�e Depanment d Loral Govemm¢nt Finance
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�Information contained in this doaiment is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-i.t-72-12(b�. �qy �tl11O
1NSTRUCTIONS:
To be (iled in person or by mail with the Counly Auditor ol fhe county where the p�operty is locafed. �p—y�,l,
Filing Dates: 7J Real P�operty: Dunng the 12 months before June 77 of fhe year lhe deduction is to be eNecrive�' ��
2) Mobile Homes assessed under IC 6-1_ 7-7: During the 12 months betore March 2 of<e�S�aE�Nid/vkU�ipmt.qes to
obtain the deduction.
See reverse ide for additional instructions and ualificalions.
Name of a icant (owner or contract buyer%) /�
` � // � / / e �
�
Is appllcant the sofe legal or
if name on rewrd is diBerem
Name o( con seller
Address of wnvacl seller
❑ No I �
applicant, indicate below
share of interest?
owned with someone other than spouse,
dicate wiN whom
Is �he pmperty in
ea� Froperty ❑ Molzle Home (IC 67.1-
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-7.7-12-72(b)? Is applicant disabled and una le t engage in any subsWntlal gaintul activity
as defined in IC 6-1.1-72-11(d)?
❑ Yes ❑ No es ❑ No
Is ihe property used and occupied primarily for his/her residence? Dces the applicanPS taxable gross income (or the preceding calendar year
exceed $17,000?
❑ Yes � No ❑ Yes No
azin �sUict Key number I Legal descriptlon Record number age number
- /o s�ao% �a -oa
IMIe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
.
/ Atltlresrs�o( app6cant � � A � Address of authorized
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representative