Disabilty_Wood°"' APPLICATION FOR BLIND OR DISABLED PERSON'S c a veaR
- DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R9 / 9-OB) �
�� d
Prasuibetl by Ne Dapannrent d Lod Grnemmenl F�ance
�forma[iom m�tainetl in Nis document is CONFIDENTIAL pursuant to IC 6-1.1-72-12(b). SEP �le N�I�'
WSTRUCTIONS:
C.`J.
To 6e fileU in person w by mail hilh the CarrtyAudRa ol the camty where tlre properly is bcafed.
Fding Dates: 7) Real Ropeily: Dunng fhe yearla wh�ch the deduction is soughf.
2) MoW7e Havnes assessed undeflC 67.7-7 or Manu/adured Homes not assessed as Real PraS18$OtQi�eYvA �s 6efae
Mamh 37 W each year the indioidual wishes to obfain the ded�xtion.
See reverse sde Ia aWifional instlucFians and qualiflcaGOns
Name d ava�m (owne.v cmbaa a,ye.J
e
Is aGGlimiN Ihe stle legal 'lade n tt rio, wr� � t�m�r a :�re d �n�n rc w.,�ed wnn so�� anar ua� :vw�.
indiole wilh wtpm:
❑ Yes ❑ No
tl name m recvd is dmerent Cun Nat d appFCanL inCimla bebw:
Name o( mntrad sa0ar '
AEtlrass d mntrad mller (munbw aM sbxl. tity. sbfn. antl ZIP mdo) ts Ne proparry in quesliort
.. � ��Y � w � �� 1.1'�
Is appiimm b6nd as Eefined in IC 12-7-2-27(7 p Ls applimnt disa0letl anC unade W ergage in arry substairt� gainlul atlivGy
az GefireO in IC Gl.1-12-11(d)?
�Yes No � Yes ❑ No
ls Ne P��M �ed aM oavP� PMa^�9 br hislher revdenca? Does Ihe a0d�n1's taxade 9ross imm�e fw Ne G�eoetla�8 nlentlar Year
ezmed 517.0009 '
�Yes ❑ No I� Yes ❑ No
ing discricl Key num�er I Lepal desoiplian Recwtl num�er Paga number
a -ai � - _Q
IIWe certi(y under penally o( perjury tha� the above and foregoing information is true and correcl and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature d applirant Address of appliont (rumDCi antl shecC crty. state. aM ZIP mtle)
/ � G- �' 7�.a 7
SignaNre da i resenla4ve P4Erass of aulhorized repasen�alive (nwn�vantl sheef, cily, �ate. and LPCOde)