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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fartn 43710 (R6 / 4-04)
Presciibed by Iha Department of Local Govemment Finanie
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In��-�ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). Fil a
6�UCT/ONS:
To be filed in person or by mail wilh the County Auditor o/ the county where the property is located. I� N 1 1 Z���
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be effectrG
z) n�ovue rfomes assessed under ic e-t i-7: Dunng the 72 months befo�e March 2 of each ye r he indivi u wrshes to
obtain the deduction. �� �
See 2verse srde for addifional inst�uctions and ualifications.
Name of applicant (owner or ntract buyer) ��
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Is applicant the sole legal or equitable owner? If No, what is hislher e ci share of interest? If owned with someone other than spouse,
� indicate vnth whom
S ❑ No
If name on record is difterent than that of applicant, indicate below
Name of contrad seller
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Address of conGad seller - Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-7)
Is applicant blind as defined in IC 12-1-1-7(n) and IC 6-1.1-12-12(b)? Is appliwnt disabled and unable to engage in any substantial gaintul activity
as defined in IC 6-1.1-12-1'I(d)?
❑ Yes ❑ No
Is Ne property used and acwpied primarily for his/her residence? Does the applicant's taxable gross inwme (or the preceding calendar year
exceed $17,000?
es ❑ No ❑ Yes ❑ No
Taxing distn Key number / Legal desuiption Record number Page number
o� �-/a-p7- /Dd-Cx�3. ��-oa� ..
IM/e 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 appliqnt Signature of auihorized representative
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dress of applicant Address of authorized represenWGve
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