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'- APPLICATION FOR BLIND OR
�� n�R O
d �. ,� DISABLED PERSON'S DEDUCTION
_. FROM ASSESSED VALUATION
State Form 43710(1-90)
�' �"" �' Prescribed by the State Board of Tax
Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
��� 2 i 199�
� AUD 70� R ���
Ap li aRt (Owner o ontr t bu L
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Is applicant the sole legai"or f no, what is his/her exact share of If owned with someone other than
e wtable owner? interest? spouse, indicate with whom.
� yes ❑ no _
T
I( name on record different than that of applicant, indicate below: "
Name of contract seller:
Address of contract seller:
�Is applicant blind as defined in IC 12-1-1-1(n) & Is the applicant disabled and unable to engage in any
IC 6-1.1-12-12(b)? subs ntial gainful activity as defined in IC 6-1.1-12-(d)?
� yes �(J no yes � no
T
Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
resi ence? preceding calen ar year exceed $13,000?
� yes � no � yes � no
Taxing District Key Number/Le al Description Record No.
Q � ��19 �a-�
Page No.
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 t, 19 .
Sign ure � Authorized Representative (by executed Power of
Attorney)
..Gdire..r.aJ
�d��/3 of AQplicant �� y 6 � Address of Representative
�o .