HomeMy WebLinkAboutDisabilty_LeathersI ��
��n„�4 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 �1
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
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pli nt wner con t er) AUD
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Is applicant t sole legal or If no, what is his/her exact share of If owned with someone other than
e wtable owner? interest? spouse, indicate with whom.
� yes � no
If name on record different than that of applicant, indicate below:
Name of contract seller:
Address of contract seller:
Is applicant blind as defined in IC 72-t-t-1(n) & Is the applicant disabled and unable to engage in any
IC 6-1.1-12-72(b)? substantial gainful activity as defined in IC 6-1.1-12-(d)?
� yes � no yes � no
s the property used and occupied primarily for his/her poes the applicanYS taxable gross income for the
re�idIence? preceding cal`enj� ar year exceed $13,000?
fXl yes � no � yes f�X no
�t� y,
ing District Key Number/Legal Description Record No.
� p�0�19 -ol5ss
���� OA�u.+-+ �� 13 3 Qkji.. Page No.:
IIWe certify under penalty oi 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
Signatyt� „� Authorized Representative (by executed Power of
L'it�� Attorney)
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� dr�,o,f Appliqant Address of Representative
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