Disabilty_Brummett��„� APPLICATION FOR BLIND OR �
d° .°„4 DISABLED PERSON'S DEDUCTION County Township Yea`r",_
�. - ' = 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.
MAY Fi�e�,'�
� � ���
AUDIT�R
Applicant (Owner or contract buyer) � � '
Is applicant the sole legal or If no,+wl�aiis his/her exact sl�co.�-- If owned with someone other than
equitabl owner? interesi? 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 defined in IC 12-1-1-t(n) & Is the applicant disabled and unable to engage in any
IC 6-1.1-12-12(b)? substan I gainful activity as defined in IC 6-1.1-12-(d)?
� yes � no yes � no
� Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
residence� preceding calendar ye exceed $13,000?
�� no � yes ��
Taxing District Key Number/Legal Description Record No.
��vc,ci� � o m t- DoD Sa- oa Page No.
I/We certify under penalty ot 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)
Address of Applicant Address of Representative