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° APPLICATION FOR BLIND OR DISABLED PERSON'S
,4 � DEDUCTION FROM ASSESSED VALUATION
�� �Slate Form 43710 (R / 9-%)
! Prescnbed by Ihe State Board ol T� Commissioners
Ir•alion contained in this dxument is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.7-72-72(b).
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor of the county where the property is loca-
ted dunng the 12 months before May i l ol the year the deduction is to be effective.
See reverse side lor additional instructions and qualilications.
Name oi appllCani (owner or
Is applicant the sole legal or
if name on record is ditterent
Name of contrad seller
Address ot contract seller
Yes ❑ No
Is applicant blind as defined in IC 12-
❑ Yes
P�aPehY
If No,
/ /
❑ No
D/ �-
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4 ! +�Y; ;.'
AUU 0 61997
GIESON
i someone other than spouse,
whom
Is applicant tllsabletl antl unable to engage in any substanlial gainful
as defined in IC 6-1.1-12(d)? �l`I yes ❑ No
���
the applicanPS tazable gross income
d $77.000?
❑ Yes ❑ No
year
I/We certify under penalty oi perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'ot the aforementioned property on March 1, 19
of applicant
of
of applican�// / � ^ ^ O / \ / /_ / n I Address ot
U �� � �