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Disabilty_Ritcheson: �.. - _�. "' APPLICATION FOR BLIND OR DISABLED PERSON'S courrrr rc , - 4 DEDUCTION FROM ASSESSED VALUATION State Fwm 43710 (R / 9�96) S � Presaibetl by Ne State Boartl ol Tar Commissioners -�� "�.�`� Irr ._.alion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-1.1-12-72(b). .�� �;L.. INSTRUCTIONS FOR FlLING: To be liled in person or by mail with the CounryAuditor of the crounty whe�e the property is loca- MaY G� 1999 ted during the 12 months be%re May i 1 0/ the year the deduction is to be ef/ective. See �everse side for additional instructions and quali(irations. � ,� or or If No, wy(a� is his/her exact ❑Yes ❑No � name on record is ditterent than that of applicanL indicate contrect Is applicant blind as defined in IC 12-7-1-t�n) and IC 6-1. P�oPertY ❑ Yes ❑ No ied primarily, tor hisfier residence? ❑Yes ❑No Kev number / Cx13S0� r � : `� J'. YEAR � 1 I with someone other than spouse, with whom t di5abletl antl unable to engage in any tantial gainful in IC 6-1.1-12(d)? es � No pplicant's tauabte gross income tor the preceding calend �,000? ❑ Yes o fiecord number Paqe number I/We certify under penalty of perjury that the above and foregoing information is true and correct and that ihe applicant was a resi- dent of Indiana and owner'of the atorementioned property on March 7, 19 iature of appli nt (� Signature of authorized representative (by executed Power o/Attomey) � � O��.S � 1�.�� ��41. of applicant . \b = d