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� °'"o APPLICATION FOR BLIND OR DISABLED PERSON'S courrrv TOWNSHIP vEna
.! - `} DEDUCTION FROM ASSESSED VALUATION
� State Form a37�0 (R / 9-96) . . .�1 '-T{-' � T�
�° ,��� � Presttihed by ihe State Board of Tat Commissioners � r�± �-J �.�� A�j i�
����ormation contained in Ihis document is CONFIDENTIAL pursuant ro IC 12-7-7-1(n) and IC 6-1.7-12-72�b).
' �-'='`" "'File Mark
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor oJ the county where the property is loca-
ted during the 12 months betore May 17 0) the year the deduction is to be el%ciive. ��.
See reverse side for additional instructions and qualifications. ,
or contract
1
� \
or eouitable
L�"1'es ❑ No
�
tl name on record is diHerent Ihan that of applicant, indicate beiow
coniraci se
Iv
of contract
Is applicant blind as defined in IC 72-1-1-1(n) and IC 6-1.1-12-12(b)?
P�oPertY
❑Yes �No
Yes ❑ No
exact share ofinterest?
OCT � � 1999
/ Lf.
I with someone other ihan spouse,
with whom
applicant disabled and unable to engage in�any subsWniial gainful activiry
� defined in IC 6-t.t-12(d)? �Yes ❑ No
gross
❑ Yes ❑ No
year
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 �
Signature of
Addr�f applicani
ao� �• �