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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R6 / a-04) .
Prescribed by the Department of Local Govemment Finance
OU T S YEAR
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In'� afion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-t(n) and IC 6-1.7-12-72(b). ,f �f N ���Q�l�
I��UCTIOfdS:
To be filed in person or by mail with the County Auditor of the county where the propeRy is located. `-y�� �
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 of the year the deduction is to be effectl�fe`� "
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months before March 2 o�g�py��j�pKii�¢St�ishes to
o6tain the deduction.
See 2verse side for additional instructions and ualifrca6ons.
Name of applicant (owner or contract buyer) �
Is appiicant the sole legal or equit le own . If No, what is hisRie exact share of interest? I( owned vrith wmeone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on rewrd is difterent Nan that of applicant, indiwte below
Name of contract seller
Address of contract seller Is the property in questlon:
� ❑ Real Property ❑ Mob�le Home (IC 61.1-7)
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-72-12(b)? Is applicant disabled and unable to engage in any substantial gain(ul activity
as definedin IC 6-7.1-12-11(d)?
❑ Yes o ❑ Yes No
Is ihe pmperty used and ocwpied primarity for hisMer residence? Does the applicanPs taxable gmss income for the prece ing calendar year
� exceed 517,000?
❑ No ❑ Yes No
Tabng district Key number / Legal description Rewrd number age number
�d 'd%- -000 .O -U0
I/We certify under penalty of perjury that lhe 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, 20 _
Signature of applicant Signature of authorized represeniative
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Address ofa ica Address ofauthorized representative
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