Disabilty_Pegram~�`"'v APPLICATION FOR BLIND OR DISABLED PERSON'S
1 DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43770 (R / 9-%)
�' u� Prescn6ed by the Slete Board of Tax Cammiuioners
In�. ..�aGon contained in this doc Iment is CONFIDENTIAL pursuant to IC 12-1-7-1(n) and IC 6-1.1-72-72(b).
INSTRUCTIONS FOR FILING:
To be filed in person or by mail with the CounryAuditor o! the aounty whe�e the property is loca-
ted du�ing the 12 months before May 17 of the year the deduction is to be elfective.
See reverse side lor additional inshuctions and qualilrcations.
�
COUNTY TOWNSHIP YEAp
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APR 30F'�g�`�`
(,�:� .�• �-s
AUDITOR
Name of applicant (owner or contract bvyer)
I
e -,-a��, I �err� Sa►,�es
Is applicant th ole legal or equitable owner? tl No, at is his/her exact share of interest?. If�owned with someone other than spouse,
�I � indicate with whom
GiYes ❑ No L
tl name on record is ditterent than that of applicant, indicate below
Name of contract seller
Address of contrad seller
Is applicant blind as defined in IC 12-7-1-t�n) and IC 6-1.1-72-12(b)? Is applicant disabled and unable to en9age in an/y.substantial gainful acfiviry
as defined in IC E7.1-72(d)? IQ'Yes ❑ No
❑ Yes ❑ No
Is the properry used and occupied primarily, for his/he� residence? Does the applicanPs tauable gross income for the preceding calendar year
- ezceed $17,000? ���
❑ Yes ❑ No ❑ Yes LLLflo
�Ta,cing district Key number / Legal description Record number Page number
n�O� �5-C��38�C�-oa
.\
I/We certity under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent o( Indiana and owner'of the aforementioned property on March 1, 19 ��.
Signature of 'cant � Signature of authorized representative (by executed Power o/Attomey)
Address applicant Address of authorized representative
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