Disabilty_Crain._i �
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�n„� APPLICATION FOR BLIND OR
d° °, DISABLED PERSON'S DEDUCTION
. FROM ASSESSED VALUATION
��� � State Form 43710(1-90)
�� `^" �� Prescribed by the State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
U'•r�n.a. ,d e�
AUDITOR�
Applicant ( er or contract,tjuyer . � A�
� `r�"
Is applicant the sole le I or If no, what is his/her exact share of If owned with someone other than
e it ble owner? interest? spouse, indicate with whom.
� yes � no
If nam on record diffe�nt than that of applicant, indicate below:
J- \l c��..��
Name of contrac eller:
Address of contract seller:
Is applicant blind as defined in IC 72-1-t-1(n) & Is the applicant disabled and unable to engage in any
IC 6❑-1.1-12-1�? s b�tial ga�i❑nful activity as defined in IC 6-1.1-12-(d)?
yes no yes no
�Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
residence? preceding calend r year exceed $13,000?
� yes � no � yes �o
Ta�cing District Ke�NumbelLLegal_Description Record No.
-f3Qi 3-F�S---��
, � 3�, Page No.
1 c�� +�E a4-3-11
1/We certity under penalty of perjury that the above and foregoing information is true correct and that the applicant
was a resident of Indiana and owner of the aforementioned property on March 1, 19�.
ignature Authorized Representative (by executed Power of �
, Attorney)
ddress of A licant Address of Representative