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i APPLICATION FOR BLIND OR
r•°•b4 County Township Year
d ,�. � DISABLED PERSON'S DEDUCTION
_. - = ; FROM ASSESSED VALUATION
�..,,,,e1�;..� StateForm43710(1-90) Fi�r3so.� �,efr,�c,s� /4�''
Prescribed by the State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
File Mark
�����
JUL � 9 1996
Applicant (Owner or c�act buyer) � ,S
�/o,�-r,•l �r%�-./ �1�- AUDITOR
Is applicant the sole legal or If no, what is his/her exacj 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 appiicant disabled and unable to engage in any
IC 6-1.1-12-12(b)? substantial gainful activity as defined in IC 6-1.1-12-(d)?
� yes � no �es � no
Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
residence? preceding calendar year exceed $13,000?
0 yes � no � yes � no
Taxing District Key Number/Legal Description Record No.
F,ei+..�usco ni2_ o0�3S�-o� PageNo.
I/We 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 on March 1, 19�.
Signature Authorized Representative (by executed Power of
) � Attomey)
V
dress of Appliaant Address of Representative
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