Disabilty_Hulfachor�..=:.�
""'°'"o APPLICATION FOR BLIND OR DISABLED PERSON'S courrr� TOVYNSHIP YEAR
r! -� DEDUCTION FROM ASSESSED VALUATION �'��
� State Form 43710 (R / 9-96)
S � �
PreSCribetl by lhe State Boattl of Taz Commi55ioners �
1 Mark
����ormation contained in this document is CONFIDENTIAL pursuant to IC 12-t-t-7(n) and IC 6-1.7-72-12(b). DEC 1 4 �9
INSTRUCTIONS FOR FILING: /� �
To be filed in person or by mail with the County Auditor ol the county where the property is loca .—.; ,� R
ted during the 72 months be%re May i l ol the year the deduction is to be effective. :;_� �' q�D1T�
See reverse side (or additional instructions and qualilications. G��S�;a r:�� !TY ,
Name of applicam (owner or contracl buyer)
_ _- -- �
Is applicant the sole le r equitable owner? It No, what is his/her ezaci share ot interest? If owned with someone other than spouse,
� indicate with whom
G`''Ves ❑ No
If name on record is difterent than thai of applicant, indicate betow
Name of coniract seller
Address of contract seller
Is applirant blind as defined in IC 12-1-1-1(n) and IC 6-1.1-12-12(b)? Is applicani disabled and unable to engage in"any substantial gainful activity
� � as defined in IC 6-7.1-72(d)? ,J,�Yes ❑ No
❑ Yes L�'No
Is ihe property used and occupied primarily for hisfier residence? Does the applicant's ta�cable gross income for the preceding caiendar year
�� exceed $77.000?
� L,7Yes ❑ No � ❑ Yes ,B�No
Ta�cing district _ Key number / Legal description Record number Page number
-' -�- — �
I/We certify under penalty of perjury that the above and (oregoing in(ormation is true and correct and that the applicant was a resi-
dent of Indiana and owner o( the aforementioned property on March 1, 19 �. •
Siqnature of applicant Signature of auihorized representative (by executed Power ofAttorney)
Address of applicani Address of authorized representative