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�°'" APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R / 9-96)
�' ,� � Presaibed by Ne Stata Board of Tan Commissioners
Ir.ation contained in this dxument is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-1.7-12-12(b).
INSTRUCTIONS FOR FILING:
To
.
applicant disabled and una
defined in IC 61.7-72(d)?
COUNTY TOWNSHIP YEAR
��� A��
MAY 0 6 1997 �
�
i
�lacn.� �ny, ry A:IO�TOR .
with someone other than spouse,
with whom
engage
❑ No
❑ Yes ❑ No
the property used and occupied pri rity_ for his/hei residence? Does the applicanYs tazable gross income for the preceding caie ar year
ezceed $17,000?
es O No ❑ Yes No
�� 9 district . Key number / Legal description Record number, Page number
-� �-1- - -D� �'
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 o( Indiana and owner'of the aforementioned property on March 1, 19 _
authorized representative (by executed Powe� ofAttomeyJ
Address of authorized representative