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� APPLICATION FOR BLIND OR
.��°•"4 County Township Year
a ,�. ,� DISABLED PERSON'S DEDUCTION
:, —� ; FROM ASSESSED VALUATION
� .• State Form 43710(1-90) �
'� �'•'• - prescribed by the State Board of Tax Commissioners �'r �
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions. M,�
Applicant (Ooypgr or
Is applicant the sole
equda owner?
[�yees � no
name on
Address of contract seller:
Is applicant blind as
IC 6-1.1-12-12(b)?
� yes � no
ii • i
If no, wh
interest?
12-t-1-7
exact
MAY 0 6 1991
�, ,�. n�.�
AUDITOR
u ownea wicn someone o�nei
spouse, indicate with whom.
applfcant dfsabled antl unabie to engage in any
ntial gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Is the property used and occupied primarily for his/her poes the appiicanYS taxable gross income tor the
residence? preceding caler�ar year exceed $13,000?
� yes � no � yes � no
Taxing District Key Number/Legal Description Record No.
C�� �.�" /U al � /9 - .2 - 9_ . 7 `%a�.
dOo� � o D25��1.- 00
Page 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 t, 19 .
Signature
^ I? �^-.�,G .� � r
G/SCo
Authorized Representative (by executed Power of
Attorney)