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APPLICATION FOR BLIND OR
: �•n
a ,�: °, DISABLED PERSON'S DEDUCTION
. —=' •= FROM ASSESSED VALUATION
��.,.,1e.: ;•� State Form 43710(1-90)
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.
Applicant (Owner or r t b yer) /
�
Is applicant sole le al or If no, what is
equitab wner? interest?
yes � no
If name on record difc�yyeqyyttyan ihatgf ap�am
Name of contract sell3r: I���—
Address of contract seller:
is appucarn ouno as
IC 6-1.1-72-12(b)?
� yes � no
� � � �
� 1� � � �
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� + � �i � ��_: i i
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"(�aY — 6 1994
�
It owned with someone othe
spouse, indicate with whom.
Is the ap ant disabled and unable to engage in any
subst ial gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Is the prop used and occupied primarily for his/her poes the applicanYs
reside � preceding calend �
yes � no � yes no
Tax ng Distric ` Key Number/Legal Description
C� l �-�ba�`7-Qo
ible gross income for the
exceed $13,000?
/We�nder 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
Attorney)
of AppliF�nt V ,.., _ � Address of