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�v, APPLICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSHIP reaR
DEDUCTION FROM ASSESSED VALUATION
State Form a3770 (RS / 6-03)
, PresaiOed by the Department of Lxal Govemment Finance
��/I ���rmalion contained in Ihis document is CONFIDENTIAL pursuant to IC 12-t-t-1(n) and IC E7.1-12-12�6). File Mark
1 'JCTIONS ' A�
l.,e fled in person or by mail with the Counry Auditor of the county whe�e the properiy is /ocated. g �� � ��
/ Filing Dates: i) Real Property: During the 12 monlhs before May 11 of the year the deduction is to be eHective.
2) Mo6ile Homes assessed under IC 6-1.1-7: During the i 2 months before March 2 0/ each year� �e`inc�iviv u�a JU�shes to
obtain the deduction.
See reverse side (or additional instructions and ualifications. � � �%
Name of appliwnt (owner o� contra J FI� %� /� //
�,y� /IL�NJ�%• f��_rw-
��/� w�� �,. �`%`1� �yili G!9S0?t C,GJldTY AIlf�.�?(�•
legai or equitable ovmef.� � If No,
name on recortl is tlitterent U
ame of contract se r
�
ddress of conVa s ler
aoolicant blind as defined in
Yes ❑ No I
that of applicant, indicate below
12-1-7-7(n) antl
X s O No
used and ocwpied
❑ No
With Someone other than SpoUSe,
with whom
Is the property in question:
❑ Reai Properiy ❑ Mobile Home (IC fr1.1-7)
applicant disabled and unabie to engaga in any substantial gainful activity
. defined in IC 6-1.1-12(d)?
;�Yes �o
c'�
calendar year
pYes ❑No
Page number
I/We certify under penalty of perjury thal 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 _
of applicant