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�n;,� APPLICATION FOR BLIND OR
d�. °,� DISABLED PERSON'S DEDUCTION County Township Year
: FROM ASSESSED VALUATION
�. .� � . State Form 43710(1-90)
�'°" , Prescribed by the State Board of Tax Commissioners
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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
Is applicant the sole legal or
eqwta e owner?
yes � no
name on
Address of contract seller:
Is applicant blind as
IC 6-1.1-12-12(b)?
� yes � no
'ff no, what is his/her exact
interest?
indicate below:
�[�AY - 5 1994
It OwnQtl with SOR1EOnB OthB
spouse, indicate with whom.
Is the applicant disabled and unable to engage in any
subst al gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Is the property used and occupied primarily for his/her poes the applicanYs t xable gross income for the
reside9�e? preceding calen year exceed $13,000?
�Y yes � no � yes no
"D°
Taxing District Key Number/Legal Description Record No.
P-�pn,� /��Q--�JE3(��Ci Page No.
w• � Sy—k�--
I/We 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, 19
S, ignat�e /� �`/��� Authorized Representative (by executed Power of
V }N7� �- �� Attorney)
oi Appiic�r� � , � � Address of Represe