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/—.� APPLICATION FOR BLIND OR DISABLED PERSON'S
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DEDUCTION FROM ASSESSED VALUATION
�` z S�ate Fortn d3710 (R7 / 5-Ofi)
Presvibed by Ihe Departmeni W Loral Govemm¢nt Finance
COUNTY N YEAR
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�^ Infortnation contained in this document is CONFIDENTIAL pursuanl m IC 12-7-7-7(n) and IC 6-1.1-1242(b�. �Urf 1 1F���
�NSTRUCTIONS:
To be filed in person or by mail with fhe County Auditor o7 the county where fhe property is located. �
Filing Dates: 1 J Real Property: Dunng the 12 months before June 17 ot fhe year fhe deduction is to be
2) Mobile Homes assessed under IC 6-L 7-7: During the 72 months before March 28f� ���n b�ljq�ishes ro
obtain the deduction.
See reverse side Ior additional insfnrr.tinn.c and ���al���as.,��
of p �cant (owner or con(ract buyer)
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appliwnt the sole legal or equitable owner? � If No, what is hisfier exaU share
❑Yes ❑No
name on record is different than that o( aooliran
appliwnt blind as
❑ Yes ❑ No
property used and occupied primarily for his/her
❑ No
a�ting district
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If owned vrith someone
indicate wiN whom
Is lhe property in question:
than spouse.
❑ Real Property ❑ Mobile Home (IC 6-t.t-7)
L72-12(b)? Is applicant disaWed and unable to ergage in any wbstantial gainful activiry
as defined in IC 6-7.1-12-�1(d)?
�Yes ❑ No
;idence? Does ihe applicanfs taxable gross income for the preceding calendar year
exceetl $17.000?
� number / Legal descriptlon Record number
6-14-18-3ol-Doo.383-0 �
❑ Yes ❑ No
I/We certify under penalty of peryury that the above and foregoing information is true and correct and Ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
of applicanl 'n/^/' -_�' /
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b/ �.,le�hn �t• Address ot authorized representative
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