Disabilty_McGlone""° � APPLICATION FOR BLIND OR DISABLED PERSON'S
; DEDUCTION FROM ASSESSED VALUATION
,� ; State Fonn 43710 (R6 / a-04)
Prescribed by the Department of Local Govemment Finance
COUNTY TOWNSHIP T YEAR
� .� �
In� -�a6on contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.7-12-12(b). File Mafk
ir�ucnoros: JUN u 6 Z006
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: Dunng the.12 months belore May 11 of the year the deduction is to be effective.�/%a� ,Q�
2) Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months befo�e March 2 of each ye [t e individual wishes to
obtain the deduction. - ���S�N COUNTY AUDITOR
See reverse srde for adddional instructions and oualificatinnc
Nam of ap licant (owner or
Is app icant the le legal or
If name on record is different
Name of conUact seller
Address of contracl seller
Is aoolicant blind as defined I
property used and
�
what is hislher exaU share of
�Yes ❑ No �
than that of applicant, indicate below
tt owned vnih wmeone
indiwte with whom
Is the property
C 12-1-1-7(n) antl IC 6-1.1-12-12(b)? Is appliwni disabled and uAable tc
as defined in IC 6-'1.1-12-i'I(d)?
❑ Yes �No
ed primarily for his/her residence? Does Ne applicanPS taxable gross
exceed 577,000? �
�4es ❑ No
� Key number / Legal descriptlon Rewi
—� � / CJ — �--�J
spouse,
il Property ❑ Mobile Home (IC 61.1-7)
engage in any substantial gainful activity
�Yes ❑ No
ncome for the preceding calendar year
❑ Yes ❑ No
IPNe certify under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of the atorementioned property on March 1, 20 _
�
E �ji%/ � % �D• ���/
of authorized representative
authorized representative
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