Disabilty_Barrett (3)APPLICATION FOR BLIND OR DISABLED PERSON'S
. DEDUCTION FROM ASSESSED VALUATION
� Stata Fortn 43710 (R9I4O8)
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PtastnCeE by Ne Oapmiment d Loral Gm�ammanl Firunce
�nforma[ion oontainetl in this document is CONFIDENTIAL pursuaN to IC 6-1.1-12-12(b).
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INS7RUCTlONS:
To be fileU in person or 6y mail with (he CamtyAUQ�dor o/ the owmty wfiere fAe poperty is bcated. �i�
Fdirg Dales: 1) Real Property: Dunrg Na year /or whirh the tletlur,tipi is soughl.
2) MoW7e Homes assessed uMer7C 6-7.7-7 w Manufactured Homes irot assessed as Real Prop��g � (�� belae
Malch 31 W each yeai fhe irrdividual wishes to obfain the deducfion.
See reverse sde (or adddional insWctions and qualificafions.
Nama d pGtstp (uwrw or confract� �
L1/
Is app&aM Iha s e legal or epuitade owneR tl No, Wut is
❑ Yes ❑ No
If �ma on remrd is dilfereni than Ihat d appfimnt inEipte babw:
Nanre of mNraU se0er
Pddrass of mnitad sa0ar (numDer and s7eef. ciry stato. aid Z1P mEO)
Ls applieM bGM az defined in IC 12-7.221(1)?
❑Yes []No
Ls Iha P�o�M �sed aM orcuP�d P�abY fw �isrt�ar resAexe?
�Yes
g tlistx� n
� ' . '^�/ `"� "�
❑ No
Key number I Legal Cesaip�ion
tl onied wah someoia olher Wn sW�+m.
indiote wi�h wlqm:
iM in WeSbn:
Property Q Mrwa�yAssess�
Nbade Flame (IC 61.1-�
Is appiimm disaDleE antl unade to ergaga in arry subsWtlial gairdul atlivily
as defi�d in IC Gi.i-12-17(d)?
�Yes ❑ No
ez�ed
Remtd numbar
❑ Yes ❑ No
I/We certify under penalty of perjury thaf Ihe above and foregoing in(ormalion is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on Maich 1, 20
appficam
representative
Pddrass af applioM (nurnber arW sboeG cdy, sfate. aM
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Addrass of aultwrizatl reorewma�ive (numDer aM sheef. cAy, stafo, and LP codo)