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APPLICATION FOR BLIND OR
a•.°'°4 County Township
e .�. � DISABLED PERSON'S DEDUCTION
�. FROM ASSESSED VALUATION
.,. 1e,� .,•� State Form 43710(1-90) � L� (� � n
Prescribed by the State Board of Tax Commissioners 7'j� ��,(,Uy�
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. „
Applicant (Owner or
Is applicani the sole
equita owner?
yes � no
If name on record di
Name of contract se
Is applicant blind as
IC 6-1.1-12-12(b)?,
� yes �o
the pro�rty used and occupied
yes � no
District
If no, wh
interest?
for his/her
exact
Year
�3
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�EP 14.1993
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If owned with someone other than
spouse, indicate with whom.
apphc i-�sabled and unable to engage in any
gainful activity as defined in IC 6-1.1-12-(d)?
yes � no �
Does the applicant's
preceding calendar
� yes no
� gross income for the
exceed $13,000?
Page No.
I/We certify under penalty of perju information is true and correct and that the appiicant
was a resident oi Indiana and owner of the aforementioned property on March 1, 19 .
Signature
Authorized Representative (by executed Power of
Attorney)
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