Disabilty_Potts�
�,,,n APPLICATION FOR BLIND OR County Township Year
a� '� DISABLED PERSON'S DEDUCTION
, FROM ASSESSED VALUATION
State Form 43710(1-90) � �
.�~�� '°" � Prescribed by the State Board of Tax Commissioners
Instructions for filing: � p��Y 1rF��cr�rk
To be filed in person or by mail with the County Auditor of the r,
county where the property is located during the 12 months befo-: �� ���'`a`f-S
May 11 of the year the deduction is to be effective. See revers� ; �AUDITOR
for additional qualifications and instructions. .
or
Is applicant the sole
equita le owner?
yes � no
If name record di
Name oi contract se
Address of contract
or Iit no, wh
interest?
Is applicant blind as defined in IC 12-1-1-1(n) &
IC 6-1.1-12-12(b)?
� yes �no
Is the property used and occupied primarily for his/her
residen .
yes � no
ot IIt owned with someone othe
spouse, indicate with whom.
v���r.c
Is the applicant disabled and unable to engage in any
substantial gainful activity as defined in IC 6-7.1-12-(d)?
�s � no
Does the applicanYs taxable gross income tor the
precedi alendar year exceed $13,000?
yes � no
D 7
Record No.
I/We certify under penalt� of perjury that the above and foregoing information is true and correct and that the applicant
w==-�.•�°�a^^• -"-"--- —' - ---rementioned property on March 1, 19 .
Authorized Representative (by executed Power of
Attorney)
. t^