Disabilty_Schmitt...,,
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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 43710 (R6 / 4-0a)
Prescribed by Ne DepartmeM ol Local Govemment Finance
C TY TOWNSHIP YEAR
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Ir -�ation coniained in this document is CONFIDENTIAL pursuant to IC 72-1-1-1(n) and IC 6-1.1-12-12(b). �AY ��I��005
l�?UCTIONS:
To be �led in person or by mail with the CountyAuditor of the county where the propeRy is located. �-y,,
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0( the year the deduction is to be effeetid� ,Q
2) Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months befo�e March 2 of �g��g���indiv�al wishes to
o6tain the deduction. NTy AUDITpq
See reverse side for additional instrucfions and ualifications.
Name of applicant (owner or confract buyerJ
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Is applicant the sole legal or equdable owner? o, what is hisRier exact share of inlerest? If owned vriih someone other than spouse,
- indicate vrith whom
s � No
If name on record is diBereni ihan that of applicant, indinte below
Name of contract seller
Address ot wntract seller - Is the property in question:
eal Property ❑ Mobile Home (IC 61.1-7)
Is appliwnl blind as defined in IC 12-1-1-1(n) and IC 6-7.1-12-12(b)? Is applicant disabled and unable lo engage in any subslantial gainful activiry
as defined in IC 6-7 J-12-'It(d)?
❑ Yes o es ❑ No
Is Ne property used and occupied primarily for hislher residence? Does the appliwnCs taxable gross income for e preceding calendar year
� exceetl $17,000?
es ❑ No ❑ Yes
Taidng disVict - Key number / Legal description Record number Page number '
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IMIe 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 _
Signature of applirant Signature of authorized representative
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Ad ess of applicant Address ot authorized representative
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