Disabilty_Menke: ;,
�AgPLICATION FOR BLIND OR DISABLED PERSON'S
� � DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R / 9-96)
S,�w � Prescribed by the State Board ol Tsc Gommissioners
Ir.�Gon contained in this documeni is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.7-12-72(b).
INSTRUCTIONS FOR FILING:
To be filed in person or by mail with the CountyAuditor of the county whe�e the property is loca-
ted during the 12 months belore May i l o/ the year the deduction is to be effective.
See reverse side /or additional instructions and quali/ications.
Name of appliwnt (owner or contiact buyer) �
__ e �
4 �ClUQC�� .)
�er. tl No, what is his/her exact
�Yes ❑ No I
If name on record is ditterent Ihan that of applicant, indicate
contract
Is applicant blind as defined in IC
property
z-,-,-,c�, a�a c s-,.,-Z,�,a .. _i
Yes ❑ No
primarily. tor hislher residence? I
f
�'es ❑ No
JAN 0 8 1997
GIGSON
y+rth someone other than spouse,
with whom ,
3�J O17�<'7 0?%� ��
1 di � ted and unable to engage in y substanliai g inful activity
in IC 67.7-12(d)? �j(es � No
pplicant's taxabte gross income tor the preceding calendar year
❑ Yes o
number Page number
l'X�'+on Oo �-poa�8-o
I/We certify under penalty of perjury that t e a rrect and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned property on March 1, 19
iature of applicant Signamre of authorized representative (by ezecuted Power olAttomey)
idress ot applicant
�1', . � �� �/
of authorized representative
a