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��� 4� APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr TOWNSHIP rena
� DEDUCTION FROM ASSESSED VALUATION
s
Sia�e Form d3710 (R7 / 5-06)
�.�� .:
Presa�bed hy If�e Deparhnent of Loral Gwemmenl Finance
niorma�ion contained in this documeni fs CONFIDENTIAL pursuanl to IC �2-1-1-1(n) and IC 6-7.7-72-12(b�. MAT �IJ V L�1�$
NSTRUCTIONS:
To 6e filed in person or by mail with the County Audifor ol the county where (he propeR s focafed. �J'/ ��
Filmg Dates: i) Real PropeRy: Ouring the 12 months 6efore June 11 01 the year the d uction is to 6e effec Le° `
2) Mo6ile Homes assessed under IC 6-1. 7-7: During !he 12 monlhs 6e re March 2 0! eact� �j��i�' ' qelpti8q�p6o
obfain the deducNon. . 1 [�i n�
lifional instructions and
orconVactbwed �
or
❑ Yes O No
name on record is difterent ihan that of applican
of conVact seller
Idress of conUact seller
applicanl blind as defined in IC 72-7-
❑ Yes
�he property used and occupied prim
No, what is his/her
below
and IC 6-1.1-12-12(b)?
Yes ❑ No
as
Does the
exceed S
I with someone
with whom
Is the property in questlon:
spouse,
��Real Property O Mob�le Home (IC G1.1-7)
t disabled and unable to engage in any substandal gainful activity
in IC 6-1.1-12-17(d)?
I�Yes ❑No
pplicanYS laxable gross income (or the preceding caiendar year
❑ Yes ❑ No
number / legal description Rewrd number Page nui
o-/a -D� -3oy-oo�.
,��, _ o �8
IMle 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 _
gnature of applicant SignaWre of authodzed representative .
_ _. _��_�... ' - e 7- ! J
.l'J �.(,� : �tJL`LVi'LC�/� �G. � /1 �
authorized representative