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"'" �tAPPLICATION FOR BLIND OR DISABLED PERSON'S ��
�, .
. •��� DEDUCTION FROM ASSESSED VALUATION
a� -� . State Form <3770 (R4 / 70-07) �"^
5��,�' ��
Presaibed by �he Depanment of Local Government Finance
COUNTY TOWNSHIP YEAR
.�
�Tnation contained in this document is CONFIDENTIAL pursuant to IC 12-7-i-1(n) and IC 6-1.1-12-12(b). Fil2 Mark .,
lRUCTIONS:
To be filed in person or by mail with the County Audrto� of the co�nty where the property is located.
Filing Dates: 1) Real Property: During the 12 montirs 6efore May 11 of fhe year the deduction is to be ef/ective.
2) Mobile Homes assessed Lnder IC 6-1.1-7: Between January 15 and March 31 of the year fhe deduction is to be effective.
See 2verse side (or additional instructions and qualifications.
Name of aDP���nt (owner or cont2ct 6uyed _
applicant [ne sole iegai or
name on record is difteren
ame of contrad seller
idress of contract seller
aoolicant blind as deflned
❑Yes ❑No
Nat of appliwnt, indicate below
❑ Yes ❑ No
ezact share
If owned with someone other than spouse,
indicate with whom
; the property in question:
❑ Real Properiy ❑ Mobiie Home QC E1.1-�
in IC G7.1-12(d)?
engage in any
� Yes � No
Ne property usetl anA occupietl pnmanty for hIS/her resitlence? Dces Ne appllcant's taxable gross mcome ror Ne precetling calenCar year
, exceed 577,000?
❑ Yes ❑ No ❑ Yes ❑ No
xing district Key number / Legal desaiption Record number Page number
-'' � -— � _�
IMIe certify un r penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of authorized representative
of authorized representative