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°'" t APPLICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSHIP
<. -� , DEDUCTION FROM ASSESSED VALUATION
S ; State Fortn 43710 (R6 / a0a)
PreuribeC by Ihe Depariment of Loral Govemment Fi�ance T� �
Ir`---�ation wntained in this document is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-1.1-12-12(b). {�,� �� �� File Maik
UCTIOldS: � I� �. J 1U -
To e �led in person or by mail with the CountyAuditor o( the county where the property is locafed. r.N � 2004
Filing Dafes: 1) Real PropeRy: During the 12 months before May 11 of the year the deduction is to be effecGve.�
2) Mo6ile Homes assessed under lC 6-1.1-7: During fhe 12 months befo�e March 2 of each year the individual i
obtain the deduction. � / L/i
of applicant (owner or conhact buyer)
or
�(es ❑ No �
name on record is difterent than that of applicant, indipte below
Name of contract seller
as
the property used and
of interest? I( owned with someone
indiwte with whom
YEAR
spouse,
Is the p/rop�rty �n question:
L�lReal Property ❑ M e Home (IC Fr1.1-7)
C 12-1-1-7(n) and IC G1.1-12-12(b)? Is applicant disabled and unable to engage in any s stanlial gainful activity
as defined in IC 6-7.1-'12-11(d)?
❑ Yes ❑ No Yes ❑ No
ed primarily for hislher residence? Does the applicant's taxable gross income for the preceding calendar year
exceetl 517,000?
s ❑ No ❑ Yes No
Key number / Legal descriptlon Record number Page number
I/We certify under penalty ot perjury that the above and foregoing information is true and conect and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
532
of authorized representative
��7p IAddress of authorized represeniative
. `