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� APPLICATION FOR BLIND OR DISABLED PERSON'S
�.-,� DEDUCTION FROM ASSESSED VALUATION
State Fartn 43710 (R / 9-96)
�,� Prescribed by the State Baard of Taz Commissioners
� In�tion contained in this documeni is CONFIDENTIAL pursuam m IC 72-1-1-7(n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING:
To be liled in person oi by mail with the Counry Auditor of the counry where the property is loca-
ted during the 12 months be%re May i l ol the year the deduction is to be e(/ective.
ownetl with someone other than spouse,
indicate wiih whom
appl�cant blintl as tletinetl m IG 12-7-t-1(n) antl IG 6-7.1-12-72�b)? Is applicant disabled and unable to engage in any su sntiai gainful activi
�� as defined in IC 61.7 -12(d)? es � No
❑ Yes F�No
the property used and occupied primarily, for his/hei residence? Does the applicant's taxable gross income tor the preceding calendar year
�/ exceed $17,000? ��
� L7 Yes ❑ No ❑ Yes L7No
xmg distria Key number / Legal descriplion Record number . Page number
-� i r �7 =o o-�f93-=ov�
I/VJe 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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