Disabilty_Beasley��
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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Staie Fortn 43710 (R7 / 5-06)
Presmbed by Ihe Department d Local Govemment Fnance
COUNTY TOWNSHIP VEAR
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In(ormation contained in ihis document is CONFIDENTIAL pursuant to �C 12-1-1-7(n) and IC 6-1.7-12-12(b�. MAR 1 3�e��
INSTRUCTIONS: �
To be tiled in person or by mail wifh fhe Counly Auditor o( (he county where the property is located. �
Filing Dafes: 7J Real Property During fhe 12 months before June U of the year the deduction is to be
2) Mo6ile Homes assessed under IC 6-1.7-7: During !he 72 months befo�e March 2 of each e r� ishes to
obtain the deduction. GIBSON � NT � ���
ee reverse side (or additional instructions and uali�cations.
Jam of applicant (o� o�ntract buyer) �`//c��
/(l..n._
L�`� "`CJ
If name on
Name ot
. the sole legal or equitaWe owner? If ho, what is
❑Yes ❑No
record is difterent than Ihat of applicant, indicate below
�niract seller
conUaU seller
If owned vrith mmeone olher than spouse,
indicate wiN whom
Is the property in question:
❑ Real Property ❑ NlobBe Hpme QC G1.1-7)
Is applicant blind as defined in IC 12-7-1-1(n) and IC 67.7-12-12(b)? Is applicant disabied and unable to engage in any subsWntial gainful acGvity
as definedinlC 6-1.1-12-1�(d)?
❑Yes � No wYes ❑No
Is the proDerty used and occupied primaril or hislher residence? Does the applicanYs taxable gross inwme for Ihe preceding �alendar year
exceed 577,000?
Yes ❑ No ❑ Yes ❑ No
Ta�ti istricl
I/We certify under penalty of perjury that the above and foregoing information is Irue and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of appliwni
� �`� 4 S �,,,�_ �J
SignaWre af authorized
representa6ve