Disabilty_Tepev
°��"o APPLICATION FOR BLIND OR DISABLED PERSON'S
.!� DEDUCTION FROM ASSESSED VALUATION
�• SWte form 43710 (R / 396)
� Prescribetl by the State BaaM af Ta. Commissioners
In ormation contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-1.1-72-72(b).
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor o� the county where the property is loca-
ted during the 72 months before May 77 0/ the year the deduction is to be etlective.
See reverse side fo� additional insiructions and qualilications.
Name oi � nt (ownei or
Is applicant tl�et or
�
If name on record is diHerent
Name of contract seller
Address of contraa seiler
Is applicani blind as defined
Is the property used and occ
No, what is hisfier exad
❑Yes ❑No �
an that of applicant, indicate below
in IC t2-7-1-1(n) and IC 6-7.7-72-72(b)?
❑ Yes ❑ No
❑ No
COUNTY TOWNSHIP YEAR �
� ���
�ile; a �`� �J
�a1.�'
MAY 0'7 1999
GIBSON G`.jUi�TY A.UDITOR
ot interest? If owned with someone other ihan spouse.
indicate with whom
applicant disabied and unable to engage in an ubstantial gainful activity
� defined in IC 6-7.1-12(d)? Yes ❑ No
�es the applicanYs tauable gross income for the preceding cale r year
O Yes �'No
Record number Page number
I/We certify under penatty 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 t, 19 �
�
Address notapplicant
�
�
(by executed Power o(Attarney)