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� �� APPLICATION FOR BLIND OR aISABLED PERSON'S couNTr TOWNSHIP ve,e,R
I;�` , j; DEDUCTION FROM ASSESSED VALUATION �
S State fortn 43710 (R6 / 40a) �� J �
•N � Prescribed by Ihe Depanment of Local Govemmeni Finance
Ir' 3tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b . Fil �v1ark
I�UCTIO/dS: �O� O ] ZO�7
To 6e filed in person or by mail with the CountyAuditor of fhe county wheie the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 of the year the deduction is to 6e etfective. �
�// no.�
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months befo�e March 2 of eacli'year the individual�wishes to
obtain the deduction. � `� TY AUDi w�
See reverse side (or addifional.instructions and aualifrratinns � G18SON COUN
(owner or con jact buyer)
Is applicant the sole tegal
If name on record is diRer
Name of contract seller
Address of contract seller
Is applicant blind as defin�
Is the property used and c
�
Taxing district
or equltable owner/ ' If No, what is his/her exaU share
V
❑ Yes ❑ No
ent Nan that of applicant, indicate below
in
❑ Yes
❑ Yes ❑ No
Is applicant disablec
as defined in IC 6-�.
Does the applicani's
exceed 317,000?
ial descriptio
�O V
owned with someone oiher than spouse,
diwte vdth whom
the property in questlon:
�❑ Real Property ❑ Moble Home (IC 61.1-
and unable to engage in any subst 'al gainful activity
1-'12-11(d)?
Yes ❑ No
gross income tor the preceding calendar year
❑ Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ _
representative
representative