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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R6 / 404)
Prescribed by the Departmeni of Local Gwemment Finance
COUNTY TOWNSHIP YEAR
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Ir' etion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). t e a
u�ucrioras: MAR 1 1 2005
To be filed in person or by mail with the County Auditor of the county where the propeRy is located.
Filing Dates: 1) Real PropeRy: During the 12 months be(ore May 11 of the year the deduction is to be effect'
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 0l each ye�di�d� eiet wishes to
obtain the deduction. �. , GIBSON COUNTY AUDITOR
See reverse side for additional instructions and ualificaBons.
Name of aoniicant (ow(�r or contract buver) /1
orequRable
If name on record is difierent
conVacl seller
that
❑ No
appliwnt blind as defined in IC 12-1-1-7(n) and IC E7.1-12-�
❑ Yes
Is the property used and occupied primarily
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as defined in IC 6-1.
�No
tor his/her residence? Does fhe applicant's
exceed 577,000? �
O No
Key number / Legal descriplion
If owned with someone other than spouse,
indiwte with whom
Is lhe property in question:
� L�'42ea1 Property ❑ Mob�le Home (IC &t.
and unable to engage in any substantial gainful activi
❑ Yes ❑ No
taxable gross income for the precedinq wlendar year
O Yes ❑ No
number Page number
I/We certify under penalty of perjury thal the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
ignature of applicani Signature of authorized representative
�f applicant - � - Address of
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