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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R6/4-04) .
Prescribed by the Depanment ot Local Govemment Finance
COUNTY TOWNSHIP YEAR
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I tion rqntained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). g J` ��Fi e� ark
i�ucr�oros: MAY 1 1 2006
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to 6e eflective.
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each yea"r',the,i�iJdual wishes to
obtain the deduction. - (J U
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See reverse side for addrtional insWctions and ualifications. GIBSUN �vur �����• •�• �
Name of applicant (owner or conha r)
Is applicant the sole legal or equitabie o eR If No, what is hisltier exaU share terest? I e 'th wmeone other ihan spouse,
cate th whom
C�es ❑ No
If name on record is difterent than that of applicant, indicate below
Name of cont2ct seller
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Address of contracl seller Is the property in quesUOn:
❑ Real Property ❑ Mobile Home (IC 61.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-7.7-72-12(b)? Is applicant disabled and unable to engage in any substantlal gainful activity
as defined in IC 6-7.1-12-'I1(d)?
Yes ❑ No Yes ❑ No
Is t�e property used and occupied primarily for hislher residence? Does the applicant's taxable gross income (or the preceding calendar year
� exceed $17,000?
Yes ❑ No ❑ Yes o
Tadng district Key number / Legal description Record number P ge number
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IMIe ceAify under penalty of perjury that the above and foregoing information is true and corzect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ ;
Signature of applicant Signature of authorized representative
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Address of applicant ^' Address of auihorized representalive
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