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Disabilty_Parksr� , ; �,,,,� APPLICATION FOR BLIND OR a° °4. DISABLED PERSON'S DEDUCTION FROM ASSESSED VALUATION �� State Form 43710(1-90) ,� ""'�' Prescribed by the State Board of Tax Commissioners County Township ��� � °°° '" •RI� Mark Instructions for filing: � �, � To be filed in person orby mail with the County Auditor of the s county where the property is located during the 12 months before AUDITOR May 11 of the year the deduction is to be effective. See reverse for additional qualifications and instructions. Year Applicant (Owner or contract buyer � _ � ,('�� �.. Is applicant the sole legal or If no, his/her exact share of If wi meone other than equitable ner? interes . spouse, indicate with whom. es � no If name on record different than that of applicant, indicate below: Name of contract seller: Address of contract seller: Is applicant blind as defined in IC 12-1-1-1(n) & Is the applicant disabled and unable to engage in any IC 6-1.1-12-72(b)? substant' ainful activity as defined in IC 6-7.1-12-(d)? � yes � no yes � no ,s the prope sed and occupied primarily for his/her poes the applicanYS taxable gross income for the residenc preceding calendar xceed $13,000? es � no � yes o Taxing District Key Number/Legal Description Record No. Q ol� -�03 7 a-� Page No. I/We certify er 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 ihe aforementioned property on March 1, 19 , Signature Authorized Representative (by executed Power of KAttorney) / Addre,ss� AAplic�n � Address of Representative � �