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- APPLICATION FOR BLIND OR DISABLED PERSON'S
, DEDUCTION FROM ASSESSED VALUATION
` , State Fortn a3710 (RS I6-03)
Pres<riDed by the Depanment of Local Govemment Finance
COUNTY TOWNSHIP YEAR
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1�' ation conlained in this document is CONFIDENTIAL pursuant ro IC 12-1-1-1(n) and IC 6�1.1-12-12(b). File Matk
,�RUCnoNS: MAY 10 2004
To be �led in person or by mail with the County Auddor ol the county wheie the p�operty is located.
Filing Dates: i) Real Property: Dunng the 12 montbs before May i f oI the year the deduction is to be efrective. �� � �
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each yearthe ind�vidual wishes to
obtain the deducfion. ��ON CvUNTY��t,U ��
wner or contract
IC
CCI�(
legal or equitabl�
name on record is aitter
ame of conVacl seller
ddress of wnVacl seller
�Ye� ❑No I
an Nat ot applican[, indicate
diwnt blind as defined in IC 12-1-7-1(n) antl
❑Yes ❑No
property used and occupied primarily for his
O Yes ❑ No
3 disirict
�o���
r�
ofinterest?
I wiN someone
wilh wham
Is the properry in question:
spouse,
I❑ Real Property ❑ Mobile Home (IC E1.7-7)
applicant disabled and unable to engage in any substantial gainful activiry
�. defined in IC 6-1.1-12(d)?
❑ Yes ❑ No
�es the applicanl's tacabie gross income for Me preceding caiendar year
oo�- �7� -�O
p Yes O No
Paga number
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 7, 20 _
applicant
of aPP�� V� t V �y �lFl 7 r L
�. /
Signature