Disabilty_Hall°"D APPLICATION FOR BLIND OR DISABLED PERSON'S
4 DEDUCTION FROM ASSESSED VALUATION
� Slate Fwm 43710 (R / 9�%)
S� w� Presrnbetl Dy Ne State Board of Taz Commissioners
\
Ir tion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-1.1-12-12(b).
IN�UCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the property is loca-
ted during the 12 months be(ore May 11 of the year the deduction is to be eltective.
See reverse side lor additional instructions and qualifications.
Name of applicam (owner or co act er) ,. n �
applicant the sole legal or
name on record is
contrap
Address of conVaa seller
as
P�oPBhY
If No, what is his/her
❑ No
JAN 2 0 1999
GIBSOY
I vnih Someone oiher than Spouse,
with whom
ic t2-�-t-t(n) antl 6-1.1-12-72(b)? Is appliqni tlisabled antl unable to engage in any
as defined in IC 67.1-12(d)? ��
❑ Yes No
ied prim .for his/hei residence? Does the applicam's tauabie gross inwme tor the
exceed $17,000?
❑ No
intial gainful
O No
❑ Yes .�(
number Page
� C�O S�-o3o - o
I/We certify under pe alty f perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and o er i the aforementioned property on March 1, 19 _
iature of applicant_ �/�� Signature of authorized representative (by ezecuted Powe� o7Alfomey)
y�7�6