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� APPLICATION FOR BLIND OR DISABLED PERSON'S
!! � DEDUCTION FROM ASSESSED VALUATION
� Siate Fortn 43710 (R / 9-96)
•�' ,�,� � Prescribed by the State Board of Ta. Commissioners
orma[ion contained in �his document is CONFIDENTIAL pursuant ro IC 12-1-1-1(n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING: -
To be filed in person c; by mail with the County Auditor of the county where the property is loca-
ted during the 72 months belore May 17 0l the year the deduction is to be e/%ctive.
See reverse side /or additional instructions and qualilications.
or contract
or
name on record is different
contract
❑ No I
of applicant, indicate below
exaa
COUNTV TOWNSHIP YEAR
_ `-°`� f
�• .'
,. : Ae ik"
�DP 0 5 Z��10 /
hv
��,SOtl
I with someone other than spouse,
with whom
Is applicant blind as defined in IC 72-1-1-7 (n) and IC 6-1.1-12-12(b)? Is applicant disabled and unable to engage in�9ysubstantial gainful adiviry
as dehned in IC 6-1.7-12(d)? ���� ❑ NO
❑ Yes
Is the property used and occupied primarily tor is/her residence? Does the applicant's taxable gross income for the preceding calendar year
' exceed $77.000?
�e O No ❑ Yes
Taxing district Key number I Legal description Record number Pag number
v i
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner oi the aforementioned property on March 7, 19 _.
of
Address of authorized representative
(by executed Power of Attomey)