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APPLICATION FOR BLIND OR DISABLED PERSON'S couNTV TOWNSHIP rea.rx
DEDUCTION FROM ASSESSED VALUATION
� , State Fortn 43710 (RS / 6-03) ���]]]:1------J111 �
� PrescnDed by Me Department of Local Govemment Finance I� ' ,`.� � ,�, �
Ir.t^�a6on contsined in ihis documeN is CONFIDENTIAL pursuant ro IC 12-1-1-1(n) and IC 7.1-1 2(b). + ��Fil'e Metli `�
r�ucnoNS: FEB 12 2004 `
To oe (led in person or by mail with the County Auditor ol the county where the property is located. �`
Filing Dates: 1) Real Properry: Ouring fhe 12 months before May 11 0( the year the deduction is to be eflective. (�� n � ,
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 o/each year.the individual wishes to
ir"- �rv�w"-`y�-
obtain the deduction. ' G!550�7 COU�ITY nUDITOR
See 2verse side (or additional instructions and ualifications.
Name of applicant (owner or contract buyer) -
� n ,. � _ _ � . _ /l
applicant the sole
�T'es O No �
name on record is difrerent Nan that ot applicant, indicate
��-�,.-
Idress of conVact seller
applicant blind as defined in IC 72-1-1-t(n) and IC Et.t-
❑Yes ❑�
the pro0erry used and occupied primarily for hisRier resic
❑ Yes ❑ No
ucing district Key m
n n n .
-aaQ
If owned with someone other than spouse,
indicate with whom
O � f - 00
Is the property in question:
� I�eal Property ❑ Mobile Home (IC Cr1.1
appiirant disabled and unable to engage in any substantial gainful activit
defined in IC 6-1.1-72(d)?
�'es ❑ No
�es ihe applicanYs taxable gross income for ihe preceding calendar year
description
❑ Yes O No
I/We certify under penalty of perjury that the above and foregoing infortnation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature ot applica
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