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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