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APPLICATION FOR BLIND OR County
a°���"O� DISABLED PERSON'S DEDUCTION
FROM ASSESSED VALUATION
�.s z State Form 43710(1-90)
.� "': '�' prescribed by the State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
Is appli�ht the sole iegai or
eq�u table owner?
IX I yes � no
��,.
If name on record different tl
Name of contract seiler:
Address of contract seller:
Is applicant blind as defined
IC 6-1.1-12-12(b)?
� yes `{�j no
r�•
If no, what is his/her exact
interest?
Township � Year
F�� i ��j 1994
�r�_ •
� AUDIT�R �
If OwnQtl with �SOmQO(12 OthB
spouse, indicate with whom.
in IC 12-1-1-1(n) & Is the applicant disabletl antl unable to engage in any
subs�antial gainfut activity as defined in IC 6-7.1-12-(d)?
p� yes � no
Is the property used and occupied primarily for his/her
residence?
191 yes � no
`f"
�
Does the applicanYs taxable gross income for the
preceding cale dar year exceed $13,000?
� yes � no
�u��- � p� �J �-3-�a .,�SAC� � ._,_.._. ..
I/We certify un r pen2 of perjury that the above and foregoing information is true and correct and that the applicant
was a resident of Indiana and owner of the aforementioned property on March 1, 19 .
Authorized Representative (by executed Power of
Attorney)
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