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-APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form a3710 (R4 / 70-Ot)
PrescriheE by Ne Department of Local Government Finance
COUNTY TOWNSHIP YEAR
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�'"-mation contained in ihis dowment is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC &1.1-12-72(b). ��M
rRUCriorvs: �E B � � 2002
To be filed in person or by mail with the County Auditor o/ the county where the properfy is locate .
Filing Dafes: 1) Real Property: During the 12 months before May 11 0l the year the deduction i o be e/fecti e. /J
2) Mobile Homes assessedLnderlC 6-1.1-7: Between January 15 and March 31 ye dec%uction � to ef/ective.
See reverse side for additional instruc6ons and qualifications. GIBSON COUNTY AUDITOR
Name ot applicant (owner or contract buyer)
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Is applicant the le legal or equitable owner? If No, what is his/her exact share of interest? If owned with o eone other than spouse,
� indicate with w m
❑Yes �No
If name on record is different than that of applicani, indicate below
Name of contract seller �
Address of contrect selier Is the properry in quesiion:
❑ Real Properiy ❑ Mobile Hortie QC 61.1-�
Is applipnt blind as defined in IC 12-7-t-1(n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in any substantial gaintul activity
_ / as defined in IC 6-1.1-12(d)? /
❑ Yes L.�',aQo �,Jr s ❑ No
Is the property used and occupied primari (or his/her residence? Does ihe appli�ant's taxable gross inwme for the preceding calendar year
� exceed 577.000? — /
es ❑ No ❑ Yes LL�6
Ta�i distriG Key number / Legal descriptlon Recard number Page number
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INJe certify under penalry of peryury that the above and foregoing information is true and correcl and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Signat re of a li ni /��_ I_- � / Signature of authorized representative
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dress o applicant Address of authorized representative
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