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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fonn 43710 (R6 / 4-0a)
Prescribed by Ihe Departmem ol Lacal Govemment Finance
COUNTY TOWNSHIP YEAR
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In�• tion coniained in this documenf is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-1.1-�2-12(b). JULFiI� Marlc007
U�UCTIONS: �
To be �led in person or by mail with the CountyAuditor o/ the county where the propeRy is located. `-y,, ��
Filing Dates: 1) Real Property: During the 12 monihs be%re May 11 of the year the deduction is to be eHective�'�
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of eacl��ggp�(j��l�a�to
obtain the deduction.
See 2verse side for additional instructions and ualifica6ons.
Name of applicant (owr�r or conVacf buyer)
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Is pplicant the sole legal or equitable owner? If No, what is hislher exaU share of interest? If owned wiih someone other than spouse,
� indicate with whom
O Yes ❑ No
If name on record is difterent than that of applicant, indipte below
Name of contrad seller �
Address of contract seller � Is the property in question:
�2eal Property ❑ Motule Home (IC 61.1-7)
Is applipnt blind as defined in IC 12-7-1-1(n) and �C 6-1.7-12-72(b)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-'I.1-12-11(d)?
❑ Yes ❑ No ❑ Yes � No
Is ihe property used and ocwpied primarily for hislher residence? Does ihe applicant's taxable gross income for the preceding calendar year
� exceed $17,000?
❑ Yes ❑ No ❑ Yes ❑ No
Ta�cin �sVict Key number / Legal description Record number Page number
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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 1, 20 _
Signature of appliwnt Signature of authorized representative
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d s appliwnt Address of authorized representative .
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