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��" `"APPLICATION FOR BLIND OR DISABLED PERSON'S
� DEDUCTION FROM ASSESSED VALUATION
�� lState Fortn 43710 (R / &%)
S � O Prescribed Dy the State Boartl of T� Commissioners
Ir�ation contained in this document is CONFIDENTIAL pursuam to IC 12-1-1-1(n) and IC 6-1
INSTRUCTIONS FOR FILING:
� COUNTY TOWNSHIP YEAR
i �2 �Z�b) File Mark
To be /iled in person or by mail with the County Auditor o/ the county where the property is loca-
ted during the 12 months be%re May i l of the � ar the deduction is to be ellective. ��� �i ��
See reverse side (or additional instructions and ualifications. „�9
Name of �wnt (owner or contract buyer)� �„ l,
�- a�s�� Cll�s
r�1i 0 � S�,
,,
Is applicant the sole legal or equitable owner? H No, what is his/her exact share of interest?. I wned wi hL_s med other n spouse,
v �
Yes ❑NO C1�:-..;-�.•��'rn—, ••n�mF
tl name on record is difterent than that of applicant, indicate below
Name of contrad seller
�
Address of contraa selle
Is applicant blirM as defined in IC 12-i-1-1(n) and IC 6-1.1-12-12(b)? Isap plicant disabled and unable to engage in any substaniial gainful activiry
as defined m IC 6t.7-72(d)? V� Yes ❑ No
❑ Yes No �c
Is the property used and occupied primarily, for his/hei residence? Does the applicant's tauable gross income for the preceding calendar year
exceed $17,000?
Yes ❑ No ❑ Yes o
Taxin9 distrid Key number / Legal descriplion Record number P 9e number
�2,(' � t.�.� :_ �O a. - �'r -C� : - t
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, 19 _
Signature of applicant Signature oi authorized representative (by executed Power olAttomey)
J� •
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Addreu of applicant Address of authorized representative
�l �.� �.3�, ��c�a.ce �i 5�7G Y