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�,,,,� APPLICATION FOR BLIND OR
a :� '°,; DISABLED PERSON'S DEDUCTION
' ': -- :, FROM ASSESSED VALUATION
. +.,, ,• 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 rt
Is applicant the sole leg�
equitable owner?
� yes � no
If name on record differe
Name of contract seller:
Address of contract selle
Is applicant blind as defii
IC 6-1.1-12-12(b)?
� yes � no
Is the prop y used and
reside ?
yes � no
Or IIt n0, wh�
interest?
than that of applicant, indicate below:
the
County Township Year
��
r�.� 2 J ���vlark
�UDITO-�R �-�s
It ownetl wlth SOmeOne Othe
spouse, indicate with whom.
,�nt disabled and unable to engage in any
gainful activity as defined in IC 6-1.1-12-(d)?
� no
primarily for his/her poes the applicanYS ta ble gross income for the
preceding calendar ar exceed $13,000?
� yes no
� ' ( � � � � �
Description
53 -�
Record No.
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicani
was a resident oi Indiana and owner of the aforementioned property on March t, 19 .
Signature
Authorized Representative (by executed Power of
Attorney)