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""' �., APPLICATION FOR BLIND OR DISABLED PERSON'S
��.-�- ; DEDUCTION FROM ASSESSED VALUATION
S State Fortn 43710 (R6 / 4-0a) .
'•+ � Prescribed Ey Ihe Department of Loral Govemment Finance
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I�� 3tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). N'� e c
UCTIONS:
To 6e filed in person or by mail with the CountyAuditor of the counry where the property is located. �"l%,Q�
Filing Dates: 1) Real Pioperty: During the 12 months before May 11 of the year the deduction is to be effective. �T A p�70R
2J Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months be(ore March 2 of �d���eNa�t%i� �n�v��al wishes to
obtain the deduction. -
See reverse side for additional instructions and ualifications
Name of applicant (owner or tract buyei)
'�J L GG[J
Is applicant the wle legal or equitable owner? I( wh t is his/her ct sha2 interest? If owned with someone other than spouse,
indicate with whom
es ❑ No
If name on rewrd is difierent th n that of applicant, indicate below
Name of contract seller
Address of contracl seller Is the property in quesUon:
❑ Real Properly ❑ Mobile Home QC 61.1-7)
Is appliwnt blind as defined in IC 12-'I-1-1(n) and IC 6-1.1-72-12(b)? Is applicant disabled and unable to engage in any subsWnfial gainful activiry
as defined in IC 6-'I.1-12-11(d)?
❑ Yes I�lo s ❑ No
Is ihe property used and occupied primarily for his/her residence? Does the applicanYs taxa6le gross income for the preceding calendar year
� exceed 517,000?
es ❑ No �'es O No
Tadng district Key number / Legal description Record number Page number
��=�t��o �-�3-ao- �o► _ o�. ��l -ce5
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INVe certify under penalty of 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 o� March 1, 20 _
Signature of applicani Signature of authorized representative
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Address of applicant Address of auihorized representative �