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�n„�" APPLICATION FOR BLIND OR
.� - 4 County Township Year
a �. � DISABLED PERSON'S DEDUCTION
:: --� ; FROM ASSESSED VALUATION
• 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
than that of applicant, indicate below:
�i i ` i ;'�t
APR 8 199?
If OwnQtl wlth�SOmBOnO OthQ
spouse, indicate with whom.
Is the applicant disabied and unable to engage in any
substantial gainful activity as defined in IC 6-t.t-12-(d)?
es � no
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Is the propeRy used and occupied primarily for his/her poes the applicant's taxable gross income for the
residenc preceding calenda ar exceed $13,000?
yes � no � yes no
Taxing District Key Number/Ce al Description Record No.
ol b -�o� 8�d
�n^, I 5 Page No.
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I/We certify under pen ty of perjury that th ahove 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, 19 .
Signature
Authorized Representative (by executed Power of
Attorney)
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