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°'"v APPLICATION FOR BLIND OR DISABLED PERSON'S
,:� _ � DEDUCTION FROM ASSESSED VALUATION
Stata Farm 43710 (R / 9-96)
•� ,�„ � Prescribed by Ne State Board of Ta. Cwnmissioners
Intormation contained in this document is CONFIDENTIAL pursuant to IC 12-1-t-7�n) and IC 6-1.7-72-72(b).
INSTRUCTIONS FOR FILING:
To be filed in person c r by mail with the Counry Auditor of the counry where the property is loca
ted during the 12 months belore May 77 0/ the year the deduction is to be eflective.
See reverse side lor additional instructions and quali/ications.
COUNTY TOWNSHIP YEAR
File Mark
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Name of applicant (owner o� contract buyer) , ;'
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Is applicant [he sole legal or equi e owner? 1 It No, what is hi r exacl share of interest? If owned with someone other than spouse,
' indiCate with whom
5 ❑ NO
If name on record is difterent than hat of applicam, indicate below
Name of coniract seller
Address of contract seller
Is applicant blind as defined in IC 12-1-1-7 (n) and IC 6-7.1-72-12(b)? Is applicant disabled and unable to engage i� substaniial gainful activity
as defined in IC 6-1.1-12(d)? es ❑ No
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Is the proper�y used and occupied primarily for is/her residence? Does the applicanYs ta�cabie gross income for the preceding calendar year
� exceed $17.000?
s ❑ No ❑ Yes
Tazing district Key number / Legal descripiion Record number Page number
o'o C - 3--
IIVJe certify under penalty of perjury that the above and (oregoing iniormation is true and correct and ihai lhe applicant was a resi-
denl of Indiana and owner of the aforementioned property on March 1, 19 i � �
Signature of applican Signature of authorized representative (by executed Powe� o(Attomey)
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A ress ot applicant ���l n Address ot authorized representalive - , F
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