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�,,,,� APPLICATION FOR BLIND OR
d �. �qg DISABLED PERSON'S DEDUCTION
, FROM ASSESSED VALUATION
�• ; State Form 43710(1-90) �
: �'"" � Prescribed by the State Board of Tax Commissioners
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
for additional qualifications and instructions.
Applicant ( or
Is applicant the sole
equitable owner?
es � no
I( name on record di
Name of contract se
Address of contract :
Is applicant blind as
IC 6-1.1-12-12(b)?
� yes � no
or
interest?
than that of applicant, indicate below:
the property used and occupied primarily for his/her
� no
�%
. .<.
County Township Year
�a
e
MAY 7 1992
�AJUDITO- R �-�--
If owned with someone other than
spouse, indicate with whom.
Is the applicant disabled and unable to engage in any
substantial ainful activity as defined in IC 6-1.1-12-(d)?
es � no
Does the applicanYs taxable gross income for the
preceding calendar year exceed $13,000?
� yes no
V/ W^^-�"' IN� � NW'�� - 1 I rayc �v�.
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applican4
was a resident of Indiana and owner of the aforementioned property on March 1, 79 .
Attorney)
X
Representative (by executed Power of