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�,,,� APPLICATION FOR BLIND OR
a e�: '°.g DISABLED PERSON'S DEDUCTION County n Year
�. --= ; FROM ASSESSED VALUATION � _
State Form 43710(1-90) �
��'°'•"• prescribed by the State Board of Tax Commissioners ppR 2 0 199 '
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 (Owner or contract
[.v
equitabl owner?
es � no
If name on record
Name of contract seller:
contract
is appncam onno as
IC 6-1.1-12-12(b)?
� yes � no
interest?
12-1-1-1(n) &
exact share of
(.Y�✓�n�e'���s
AUDITOR
ir owned wrth someone othe
spouse, indicate with whom.
Is the applicant disabled and unable to engage in any
substant' gainful activity as defined in IC 6-1.1-12-(d)?
es � no
Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
residence? preceding calendar r exceed $13,000?
�es � no � yes �
Taxing District Key Number/Legal Description Record No.
Pw' ' v--t—t-�J-'—".b-3-0_C� Page No.
I/We certify under penalty of 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 t, 19 .
Signature
Authorized Representative (by executed Power of
Attorney)
Address