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� APPLICATION FOR BLIND OR DISABLED PERSON'S
:! � DEDUCTION FROM ASSESSED VALUATION
- � Stata Porm 43710 (R / 9-96)
e
y�� � Prescribed by Ihe Siate Baartl of Taz Commissioners
���.ortnation contained in this document is CONFIDENTIAL pursuant �o IC 72-7-1-1(n) and IC 6-1.7-12-72(b).
INSTRUCTIONS FOR FILING:
To be liled in person c•r by mail with the County Auditor ol the county where the property is loca-
ted during the 12 months belore May 11 of the year the deduction is to be eflective.
See reverse side (or additional insbuctions and qualilications.
Is applicant the soltlp,Aa7nr a+uit
�
If name on record is diNerent than
Name of contracl seller
Address ot contract seller
Is applicant blind as detined in IC
�
Is the property used and occupied
, /�
TauinCd3trict `
!' 1
J�J�Y..i �
owner? If No,
❑ No
❑ No
❑ No
IlWe certify under penalty ot perjury that the abo
dent o( Indiana and owner of the a(orementioned
exact share
APR 2 ) ZQ00
°ON
I with someone
with whom
..L'•�ITOR
ihan spouse,
�b)? Is appliCant tlisablEtl antl unable to engage in an stan6al gainful aClivity
as defined in IC 6-1.7-12(d)? Yes ❑ No
' Does the applirant's taxable gross income for the preceding calendar year
exceed $17,000? ��
. ❑ Yes .cfNo
/ Legal description � Record number Page number
9'-��a�sso�
ve and foregoing information is Irue and correct and that ihe applicant was a resi-
property on March 1, 19 �
Signature of authorized represeniative (by executed Power o/Attomey)
4ddress of applican , Address of authorized represeniative
c_J ,,�- � � • � /�-�-�-' .