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a, "- APPLICATION FOR BLIND OR DISABLED PERSON'S couN7v TOWNSHIP � YEAR
-�-.- . DEDUCTION FROM ASSESSED VALUATION
y� • State Fortn a3770 (R4 / 70-01)
S:: "� Prescribetl by Ne Department of Loral Government Finance
�''" '�nation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-t(n) and IC 6-1.1-12-12(b). File �a
RUCTIONS:
To be filed in person or by mail with the County Auditor o( the county where the property is located. SE P 1$ Z�02
Frling Dafes: 1) Real Property: Dunng the 12 months before May 11 oI the year the deduction is to be eBechve.
2) Mobile Homes assessedLnder IC 6-1.1-7: Behveen January 15 and March 31 of the ear the dedu fio� k to be ef/e ive.
See reverse side (oradditional instructions and qualihcations. ��,(`�„�_���
of appliwnt (owner
name on
is
❑ No I
of appliwnt, indicate below
Name of contract seller
Address of contract seller
Is applipnt blind as defined in IC 12-1-7-1(n) and
❑ Yes L7 No
Is the property used and occupied primarity for hi<
� ❑ Yes ❑ No
Taxing district
exact share ofinterest?
as
exceed
It owned with someone
indicate with whom
Is the property in Question:
spouse,
�[�al Property ❑ Mobile Home QC 61.1-
t disabled and unab e to engage in any substantial gainfui aCivity
in IC 61.1-12(d)?
�es ❑ No
ppliranPs tauable gross income for ihe preceding calendar year
❑ Yes ❑ No
P�ae number
INVe certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Address of
representative
represeniative
RECEIPT FORAPPLICATION FOR DEDUCTION FOR BLIND / DISABLED PERSONS
Name o( aDD���t Date filed (month, day, year) .
Name of contrad selter .
Ta�dn90istrid � �1 � _k ` �
1 �J i�J
mber / Legal descriptlon
SEP i 8 2002
0 0� -o a / /�
SignatureolCOUnryAUdiwr DatesiVgl��fA' � ��e?tlSUDITOR