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� ,,,,�4 APPLICATION FOR BLIND OR
d � DISABLED PERSON'S DEDUCTION
FROM ASSESSED VALUATION
t � 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 contract buyer)
or IIf no, wh
interest?
�yes � no
If name on record different
Name of contract seller:
Address of contract seller:
Is applicant blind as define
IC 6-1.1-12-12(b)?
� yes [�. no
Is the
I/We <
was a
used and occupied primarily for his/her
yes � no
�- i ;_ �. I,1
1
'� - �199�
If owned with someone other than
spouse, indicate with whom.
�e -9�'
�3ppli n disabled and unable to engage in any
gainful activity as defined in IC 6-1.1-12-(d)?
yes � no ,
Does the s
preceding
� yes
-�1/��;-0Q
iY xable gross income for the
r year exceed $13,000?
no
ier penalty of perjury fhat the above and foregoing information is true and correct and that the applicant
of Indiana and owner of the aforementioned property on March 1, 19 .
�nature Authorized Representative (by executed Power of
% O � //� Attomey)
/1� 1�