Disabilty_Abell- APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
` ' Siate Fortn 43710 (R5 / 6-03)
�� Prescribed by the Department ot Local Govemment Finance
�7
Ic`—maGOn contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC E1.1-12-1�2(b). ��'tl �� ��e M,ark
��UCTIONS: i' d � � �d � � ..f'�
o e filed in person or by mail with the Counry Auddor ol the county where fhe property is-bcated.
Filing Dates: 1) Real Property: During the 12 months before Mey 11 of the year the deduction is to be e(fecti �j
2) Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months before March 2�o% eac}� yea��r ffie individual wishes to
obtain the deduction. /� /� �%
See reverse side (or additional instrucfions and i tions. 1/ �-.� , .. l6 , Y
Name of applicant (owner or contract buyer) ^ �?-��'-'-'`r"� "`; �_` r3 �.
� _ !'� � T�1 1 ' G1350N CCI;t�TY FUD1T..
sole legal or equitable owner? � If No,
If name on record fs tlifter
Name of convact seller
Address of conVact seller
❑ Yes ❑ No �
an thai of applicant, indicate below
. applirant blind as defined in IC 12-1-1-7(n) antl IC 6
' ❑ Yes ❑ N
� tha property used and ocwpied primaril r hisTher
� ❑ 5 ❑ No
If owned with someone oiher than spouse,
indicate vrith whom
Is the property in questlon:
❑ Real Property ❑ Mobile Home pC 61.
t disabled and unab�e to engage in any subst � gainful activi
in IC 6-1.1-72(d)?
es O No
pplicanYS taxable gross income for the preceding calendar ye
I,000?
❑ Yes o
Record number Page number
I/We certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicanl was a resident
of tndiana and owner of the aforementioned property on March 1, 20 _
of applicant
39
Signature of auNorized
y'6 y� IAddress of