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APPLICATION FOR BLIND OR
�`'� �'�'� DISABLED PERSON'S DEDUCTION
�. 4 FROM ASSESSED VALUATION
�.,; r 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 contract
spouse, indicate with whom.
[�yes � no
If name on record different than that of applicant, indicate below:
Name of contract seller:
Address of contract seller:
Is applicant blind as d ined in IC 12-1-1-1(n) & Is the applic t disabled and unable to engage in any
IC 6❑-t.�-12-12(b)? substan' gaf❑nful activity as defined in IC 6-1.1-12-(d)?
es no es no
Is the pro rty used and occupied primarily for his/her poes the applicanYs able gross income for the
reside e? preceding calen year exceed $13,000?
yes � no � yes no
Taxing District Key Number/Legal Description Record No.
Qp�O — ��D�.�� PageN6.
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
Signature �„ Authorized Representative (by executed Power of •
� �) �� Attorney)
o-,�.��o a .e.>��.¢,�JI
d ss of Applicant Address of Representative -"'
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