Disabilty_Atkins��„n APPLICATION FOR BLIND OR
a �: °� DISABLED PERSON'S DEDUCTION
� ' -- i; FROM ASSESSED VALUATION
L �s ,• 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.
Is applicant the sole legal or
equitable owner?
� � no
name on
of contract seller:
Is applicant blind as de
IC 6-1.1-12-12(b)?
� yes �
Ii no, what is his/her exact
interest?
below:
. : .i_
APR 2 819Q'
�� AUDITO�R ���
It OwnQtl with SOmBOnQ OthO
spouse, indicate with whom.
-t-1(n) & Is the applicant disabled and unable to engage in any
substan gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Is the property used and occupied primarily tor his/her
residen .
yes � no
Taxing District
Does the applicanYs taxable gross income for the
preceding calendar year exceed $13,000?
� yes �
Record No.
I/We certify un�r penalty of perjury that thL above and foregoing information is true and correct and that the a�
was a resident of Indiana and owner of the aforementioned property on March 1, 19 .
Signature Authorized Representative (by executed Power of
„ „ „ � Attomey)