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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn a377o (R318-00)
Prescribed by Ne Sa:e eoard of Tax Commissioners
�rmation contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-1.7
IN�TRUCTIONS FOR FILING:
COUNTY � TOWNSHIP YEAR �
� File Mark
,2-,Zcb� NOV 0 9 2001
To be filed in person o� by mail with the County Auditor of the county where the pioperty is
ted during the 12 months be%re May 11 o(the yearthe deduction is to 6e effective.
See 2verse side (or additional instnictions and quali6cations. ,
Name of applicant (owner or conf2ct buyer)
name on
contraG seller
Is applicant 61ind as defi
Is the property used and
/
Taxin9 distriG
❑ Yes ❑ No
❑ Yes ❑ No
❑ No
exact
I with someone other than spouse,
with whom
dicant tlisabled and unable to engage ln any s antial gainful adivii
9ned in IC 6-7.1-12(d)? es ❑ NO
the aoplicant's taxable gross income for ihe preceding calendar year
d 517,000? � �
❑ Yes L.�+1Qo
1/We certify under penalty of perjury lhai the above and foregoing information is true and correct and that lhe applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
of appiicant
of