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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn 63710 (R6 / 4-Oa)
Prescribe0 Dy Ihe Depariment of Locai Govemment Finance
I` �tion contained in this document is CONFIDENTIAL pursuant to IC 72-1-1-1(n) and IC 6-1.1-12-12(b).
I�:UCTIOldS:
To be (led in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Pioperty: During the 12 months before May 11 of the year the deduciion is to be ef(ective� U N 1 j Z�Q]
2) Mobile Homes assessed under IC 6-1.1-7: During fhe 12 months before March 2 0/ each year the individual wishes to
o6tain the deduction.
ime of ap�cant (owrreu/b?�rnntract buver� �
applicant Ne sole legal ok equit�wner/? � u.o, what i is/h
�(es ❑ No �
on record is different than that of appiicant, indipte below
ltltlress ot conVaIX 4eller
s applicant blind as defined in IC 12-1-
� Yes
s the property used and occupied prim
� �E5
� / I I
exact share
I v.9th 5ome0ne
with whom
DITOR
Is the property in quesGon:
❑ Real Property ❑ Mob1e Home pC 61.
and IC 6-1.1-72-72(b)? Is applicant disabled and unable to engage in any substantial gainful acfivi
as defined in IC 6-7.1-12-N(d)?
I'No �1 Yes ❑ No
his/her residence?
❑ No
Does the applicant's taxabie gross
exceed $17,000?
❑ Yes
ey number / Legal description Rewrd number Page number
�'y-/�% �_/a/-0DO.�S-Ody
year
I/We certHy under penalty of perjury that the above and foregoing information is true and correct and that the appficant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
representative
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