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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R6 / a-0a)
Prescribed by the Depanment of Local Govemment Finance
COUNTY TOWNSHIP YEAR
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I� tion wniained in this document is CONFIDENTIAL pursuant lo IC 12-1-1-1(n) and IC 6-1.1-12-12(b). de�Merk
�}�RUCnoros: MAY 1 9 2006
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 of fhe year the deduction is to be e/fective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Dunng the 12 months be%re March 2 of each yea�;thGjndividual wishes to
obtain the deduction. d Q'
See reverse side for additional instiuctions and uali�ca6ons. GIBSON COUNTY AUDIYO�
Name of applicany(o}vner or contract buyer) � �
appiicant the sole legal or
iame on rewrd is difteren
ime of contrad seller
O Yes ❑ No
�ss of contract seller -
rlicant blind as defined in IC 12-7-1-1(n) and
0 Yes �No
properry used and ocwpied primarily for hi:
I �Yes ❑ No
indicate below
exact share of
n awned vnth someone
indicale with whom
Is applicant disabled and unable
as defined in IC 6-'1.1-�2-1�(d)?
Does
descrip6on
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property in questlon:
gross
spouse,
il Property ❑ Mobile Hwne (IC 61.1-7)
engage in any wbstantial gainful activiry
❑ Yes ❑ No
ncome for the preceding calendar year
❑Yes ❑No
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, 20 _
authorized representative
ot appucant Atldress ot authorized representative
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