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APPLICATION FOR BLIND OR DISABLED. PERSON'S couNTV TOWNSHIP reaa
DEDUCTION FROM ASSESSED VALUATION
` , State Fortn a3710 (R516-03) �, ��7-�,{
� PrescribeE Ey Ma Department of Local Govemment Finance E+,� �� � !r-1 jj `p�
Inf rtnatlon contained in Nis dowment is CONFIDENTIAL pursuant to IC 12-7-1-7(n) and IC E1.1 bz-�2(a ��"�ie Martc
j��UCTIONS: 0 8 2001�
e �led in person or by mail with the County Auditor o/ the county where the property is loca�.
Filing Dates: i) Real Property: During the 12 months 6efore May 11 0/ the year tAe dedu on is to be eHective. n �
2) Mobile Homes assessed under IC 6-1.1-7: During the 12 monlhs before M rch 2 o/e�acFi-year fhe ntdivrdual wishes to
obtain the deduction. �""���`� TY AUD� ��� •
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(owner or contract
If name on record "ts tlifter
Name of contract seiler
Address of conVaM seller
Is applicant blind as defin�
Is Ne property used and �
or equitable own R - If No, what is
es ❑ No
ent Nan that of appiicant, indicate below
in IC 12-7-t-1(n) antl IC 6-
❑ Yes L�J�vO
vpied primarily for hislher i
❑Yes ❑No
exact share of interest? It ownetl with someone otner tnan spouse,
indicate with whom
Is the property in question:
❑ Real Property ❑ Mobile Home pC E1.'
Is applicant disabled and unabie ro engage in any subs tial gainful acUvil
as defined in IC 6-1.1-72(d)?
es ❑ No
Does the applicanYS tauable gross income for ihe preceding calendar year
description
❑ Yes ❑ No
P� aae number
� � KJ h/ � I'lJ1`JJ' Vv� -�''' � I I `
INJe certify under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ •
22c, � 3�-�� ,o�er►�; �
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