Disabilty_Lemon°'° t APPr�ICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSHIP renR
-, -- ; �EDU�TION FROM ASSESSED VALUATION �
S State Fortn 43710 (R6 / 4-04) 1
� Prescribed by the Department ot Lacal Govemment Finance �
Ir tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-1.1-12-12(b). File Mark
i�ucnoros: JUL p s ZO��
To be filed in person or by mail with the CountyAuditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be eflectiv� �
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months be(ore March 2 0/ eadS}gg�e��vidu�hes to
obtain the deduction. UNTy q�DlTpq
of applicant (owner
or
❑ Yes ❑ No
name on rewrd is diRerent than that of apDliwn
of cont2ct seiler
> applicant blind as Eefir
s Ne properry used and
�
�a�dng district
Q�
No, what is
and IC 6-1.1-12-12(b)?
i vnth wmeone
with whom
Is the property in question:
spouse,
�[�FReaI Property ❑ Mobile Home (IC 61.
i disabled and unable to engage in any substantlal gainful acfivi
in IC 6-1.1-72-17(d)?
❑ Yes No Yes ❑ No
ed primarily for hislher residence? Does the applicant's taxabie gross income (or the preceding wl
exceed 577,000? �
❑ Yes ❑ No ❑ Yes �o
� Key number / Legal description Rewrd number P ge nui
Lj �(o-/Y -67 -3o0-D0o (0 4,3 - O°
year
INJe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
gnatur piicant Signature of authorized represenWtive
x \ ..��
� �\ 1 �^� IAddress of authorized
K
C i'� -.` l h
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