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�,,,n APPLICATION FOR BLIND OR
a ,�:.: `.� DISABLED PERSON'S DEDUCTION
�� FROM ASSESSED VALUATION
i State Form 43710(1-90)
�w �� '°" �� 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
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
appucant wner or en[r,
!i
Is a icant the sole legal
equitable owner?
�yes ❑ no
If name on record differert
Name of contract seller:
Address of contract seller:
Is applicant blind as definE
IC 6-1.1-12-12(b)�
� yes
If n0, wh
interest?
than that of applicant, indicate
��Y � a 199�
If owned with someone other
spouse, indicate with whom.
Is the ap licant disabled and unable to engage in any
subst ial gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
reside ce? preceding calend ear exceed $13,000?
yes � no � yes no
Taxing District Key Number/Le I Description Record No.
Page No.
!�%i� - ���-0�
INJe certify under pen Ity of erjury tha rmation is true and correct and that the applicant
was a resident of Indian n owner of the aforementioned property on March t, 19
Signature
Authorized Representative (by executed Power of
Attorney)
sss � APp�o%iToi✓ S�•� Address of Representative
1� �''� �Kl.a.rn C�T�T,v