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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (Ra / 70-07)
Prescribed by the Department of Local Government Finance
I COUNN TOWNSHIP YEAR
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��•�''Tnation contained in ihis dowment is CONFIDENTIAL pursuant to IC 12-7-1-7 (n) and IC 6-1.1-12-12(b). il2j(�rk
RUCrioNS: A P R U
To be filed in person or by mail with fhe County Auditor o! the county where the property is located. 3 2�03
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0l the year the deduction is to �effective. �
2) Mobile Nomes assessedLnder IC 6-1.1-7: Behveen January 15 and March 37 oJ t ear the deilucGc i is to �e e ective.
See reverse side for additional instnictions and ualifications. '`"�
Q GIBSON OUNt�AVGI OR
Name of appli ( vner or conbact buyer)
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Is app icant the sole legal or equitable owneR If No, what is his/her exact share of interest? If owned with someone other than spouse,
� indiwte wBh whom
Yes ❑ No
If name on record is different than Nat of applicant, indicate below
Name of contraC seller
Address of contrect seller Is the property in Quesiion:
,�Real Property O Mobile Home pC 61.1-�
Is applipnt blind as defined in IC 12-1-t-1(n) and IC 6-7.1-12-12(b)? Is applicant disabled and unable to engage in any substantial gainful aCiviry
_ as defined in IC E7.7-12(d)?
❑ Yes ❑ No ❑ Yes ❑ No
Is the property used and occupied primarity for his/her residence? Dces the applicant's taxable gross income tor the preceding calendar year
� exceed 517,000?
� �Yes ❑ No ❑ Yes ❑ No
Taxing distrid Key number / Legal description Record number Page number
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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 of the aforementioned property on March 1, 20 _
Signature of applicant , Signature of authorized representative
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tlreu of applinnt Address af authorized representative
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