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�°"D � APPLICATION FOR BLIND OR DISABLED PERSON'S
:!� � DEDUCTION FROM ASSESSED VALUATION
� State Fortn a3710 (R / 9-96)
�' �,� � PrescnDed Dy Ne Slate Board af Taz Commissioners
Ir�tion contained in this documeni is CONFIDENTIAL pursuant to IC 12-7-1-7 (n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the property is loca-
ted during the 12 months be%re May 77 0l the year the deduction is to be el%ctive.
See �everse side !or additional instructions and qualifications.
or contrac�
or
No, what is his/her exact share
es ❑ No I
name on record is ditterent ihan that of applicant, indirate below
�
Is applican� blind as defined in IC 72-7-7-7 (n) and IC 6-1.1-12-12(b)?
as
❑ Yes ❑ No
exceed $1
Yes ❑ No
courmr
� ;
� x
FEa o 3 �ssa
l�.ti.iiil�i
YEAR
It ownetl with someone other than spouse,
indicate with whom
t tlisabletl and unable to en9age in any substantiai gainful activi�
in IC 6-7.1-12(d)? �Yes ❑ No
ppliranPS tauable gross income for the preceding calendar year
❑ Yes
number �Page
I/We certify under penalry of perj�bry that the above and foregoing information is Irue and correct and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned property on March 1, 19 _
authorized represenfative (by ezecuted Power
mupplicant /1 , Adtlress of authorized representaMe
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