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. �,,,,� APPLICATION FOR BLIND OR
a �. °aq DISABLED PERSON'S DEDUCTION
' FROM ASSESSED VALUATION
�• State Form 43710(1-90)
�'°" • Prescribed by the State Board of Tax Commissioners
County Township Year
��. ��
;�EC 2 ��i�gg��k
Instructions for filing:
To be filed in person or by mail with the County Auditor of the �� ,�, �s
county where the property is located during the 12 months before AUDITOR
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
Applicant (Ow r or contract bu er)
Is applicant th ole legal or If no, what is his/her exac; share of If owned with someone other than
equitable owner? interest? spouse, indicate with whom.
� yes � no
If name on record different than that of applicant, indicate below:
Name of contract seller.
Address of contract seller:
Is applicant blind as defined in IC 12-1-1-1(n) & Is the applicant disabled and unable to engage in any
IC 6-1.1-12-12(b)? substa al gainful 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 taxabte gross income for the
residen . preceding calendar r exceed $13,000?
; yes � no � yes �
Taxing District Key Number/Legal Description Record No.
��� o � a-� o0 7 g-ao Page No.
I/We certify under penalty oi perjury that the above and foregoing information is true and correct and that the applicant
was a resident of Indiana and owner of the aforementioned property on March t, 19
Signature Authorized Representative (by executed Power of
X� Attorney)
Address of Ap licant Address of Representative
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