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��' .� APPLICATION FOR BLIND OR DISABLED PERSON'S couNrr TOWNSHIP rEnrt
,: 1 DEDUCTION FROM ASSESSED VALUATION y-� � �
' ;•f �` �+ Stale Fortn d3710 (R7l 5-06) H
Resaibed by Ihe DepaM�n�t W loral Governmrnt Fnance 1
Infortnation wntained in this documeni is CONFIDENTIAL pursuam to IC 12-1-1-1(n) and IC 6-1.1-12-12(b). File Mark
INSTRUCTIONS: SEP 2 6 ZQD]
To be /iled in pe�son or by mail wi(h Ihe County Auditor oI (he county where the property is locafed.
Fding Dates: 7) Real PropeRy: During the 72 months before June 77 of lhe year the deduction is l0 6e e� �f
2J Mobile Nomes assessed under IC 6-7. 7-7: During the 12 months 6elore Ma�ch 2/ each yea he in�dual wishes !o
obtain the deductioa ��BSON COUNTY AUDITOR
See reverse side for additional instructionc and rn�a��F�a���o�
ame of appl"� t(owner or contrac( buyer o
applicant Ne sole legal or equitable owner? If No,
es O No
name on rewrd is diHerent th n that of applicant, indicaU
applicant blind as defined in IC
❑ Yes ❑ No
property used and occupied primarily for hislher
Yes ❑ No
is his/her exaU share
1-12-72(b)?
with someone
witli whom
Is the property in quesGan:
spouse,
��Real Property ❑ Mob�e Hpne pC 61.1-7)
� disabled and unable to engage in any substanfial gainful activiry
in IC 6-1.7-12-11(d)? _
�he applicant's
tl 517,000?
imber / e al cripGon
o ����a�•
❑ Yes ❑ No
gross inwme (or the preceding calendar year
❑ Yes ❑ No
Record number Paae numher
I/We certify under penalty of perjury that the above and (oregoing information is true and covect and lhat the appiicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20
appliwnt
X
Signature o(
^�U,{r» �� ayP���3 S` . IAdaress ot authonzed representative
� 3d � �� S,t- �i,�i �. y76G�