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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Sfate Form 43710 (R6 / 4-04)
Presuibed by ihe Department of Loral Govemment Finance
1�3tion contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-1.1-12-�2(b).
COUNTY TOWNSHIP YEAR
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File Mark
I ,3UCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the prope gyqte
Filing Dates: 1) Real Property: Dunng fhe 12 months before May 11 0( the year the de��t�f k� .
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months be%r a o each year the individual wishes [o
obtain the deduction. - AP R 5 2005
See reverse side (o� add8ional instn�ctians and nualifira�inns
Name
or
IF name on record is
Name
iYes O No
that of applicant,
If No, what is hisJher exac
��DITOR
th someone other than spouse,
h whom
Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.1 •
Is applirant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any substantlal gainful activity
as defined in IC 6-1.1-12-71(d)?
❑ Yes o es ❑ No
Is Ne property used and occupied primarily for his/her residence? Does the applicanfs taxable gross income for Ne preceding calendar year
� exceed 317,000?
❑ Yes ❑ No ❑ Yes o
Ta�dn dis 'ct Key number / Legal descriplion Rewrd number Page number
�,��k.CQ,� O (�c --Od� 1 I -oa
IIWe 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 o'wner of the aforementioned property on March 1, 20 _
of authorized
0.7ress of applicant \ / ' Address of authorized representative
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