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APPLICATION FOR BLIND OR
d�. 4qq DISABLED PERSON'S DEDUCTION
�. , FROM ASSESSED VALUATION
w� 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
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.
Applicant (Owner or
Is applicant the sole
equitable ner?
es � no
name on
Address of contract seller:
or Iir no, wn
interest?
Is applicant blind as defined in IC 12-t-1-1(n) 8
IC 6-1.1-12-12(b)?
� yes �no
%
Is the pr erty used and occupied primarily for his/her
yes � no
Taxing
exac;
County
� 1
�(�Y
Township
r . .7,_
AUD�, �s
TO�.R-a �
Year
it ownetl wrth someone othe
spouse, indicate with whom.
applica sabled and unable to engage in any
gainful activity as defined in IC 6-t.t-12-(d)?
yes � no
Does the applicanYs taxable ss income for the
preceding calendar exceed $13,000?
� yes no
Record No.
�J 1%V � O I�`O � lQ / O� 0 v Page No.
I/We 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, 19 .
Authorized Representative (by executed Power of
Attorney)