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°""o APPLICATION FOR BLIND OR DISABLED PERSON'S '` courm TOWNSHIP VEAR
.! „ � DEDUCTION FROM ASSESSED VALUATION ��~
�• Sta[e Form 43710 (R / 9�96)
� Prescnbetl by the State Boartl of Tau Commissioners \\�
��ormation contained in this documeN is CONFIDENTIAL pursuant to IC 72-1-1-1(n) and IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the property is loca-
ted during the 12 months be)ore May 11 0l the year the deduction is to be eNective.
See reverse side lor additional instructions and qualifications.
Name of 'icani (owner o� conhact buye�J
l' 7, e�v�
Is applicani the sote le al or equitable owner?
Yes ❑ No
If name on record is diHerent than thai of applican
Name ot contrad seller
Address of contract seller
Is the property
If No, what is his/her exact share of interest?
C 12-7-1-7(n) and IC 6-7.1-12-12(b)?
O Yes �io
ed primarily for his/her residence?
Yes O No
Keynumber/Le
J(: 77 , ���'�—�
If owned with someone other ihan spouse,
indicate with whom
applicant disabled and unable to engage in, ya�nV� substantial gainful aciiviry
defined in IC 61.7-12(d)? y�yes ❑ No
gross
❑ Yes ❑ No
Page number
year
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 _
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