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���e�"` °" APPLICATION FOR BLIND OR DISABLED PERSON'S
4 DEDUCTION FROM ASSESSED VALUATION
Sta[e Fortn 43710 (R / 9-96)
�2.� I Prescribed by Ne State Boartl of Tan Commissioners
inrormation contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-7 (n) and IC 6-1.7-12-12(b).
INSTRUCTIONS FOA FILING:
To be liled in person cr by mail with the County Auditor of the county, where the property is IocG
ted during the 12 months be%re May i l ol the year the deduction is to be ellective.
See reveise side (or additional instructions and qualifications. �
ime of applicam (ownerorcontract
applicant the sole leg r equitabl[
name on
contrea
❑Yes ❑No �
different ihan that of applicant, indicate below
of contract seller
asdefined in IC 12-7-1-1(n) and IC 6-7.1-72-
exact
0
6-7.1-72(d)?
J•
COUNTY TOWNSHIP YEAR
File Mark
��� ��iF��,
0� A_�,_�
APR 0 � 2000
to engage
spouse,
❑ No
O Yes ❑
Is the property used and occupied primarii r his/her residence? Does the applicant's taxable gross income for the preceding calendar year
'. exCeed i77,000?
s ❑ No ❑ Yes o
Taxing district Key number / Legal descrip[ion Record number Page number
� � —�
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 �
/ p3 S •CR-,�>
representative (by executed Power olAttorney)
: