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�""�'> �APPLICATION FOR BLIND OR DISABLED PERSON'S
� DEDUCTION FROM ASSESSED VALUATION
S,+ S�a�e Form 43770 (R4/10-01)
S:� "� PrescnbeG by ihe Department ol Local Government Finance
COUNTY I TOWNSHIP YEAR
:�nation contained in this document is CONFIDENTIAL pursuant to IC 72-1-1-7(n) and IC 6-1.1-12-12(b). � a
rRUCnoNS: JUN 2 8 2002
To 6e �led in person or by mail with the County Audifor o( the county where fhe property is located.
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is t be eNective. /
2) Mo6ile Homes assessedLnder IC 6-1.1-7: Between January 15 and March 31 of e year f �� / on is be ective.
See reverse side loradditional instructions and qualifications. GBSON COUP!T'r .4UOITOR
Name of applicant (owner or contract 6uyerJ .
� � �
-- 7
Is appliwnt the sole legal or equitable owneR It No, what is his/her exact sha7e'oPinterest? If owned with someone other than spouse,
indicate with whom
❑Yes ❑No
If name on record is diRerent than that of appliwnt, indicate below
Name of contract seller
Address of contract seller Is the property in question:
eal Pmperty ❑ Mobile Home QC 61.1-�
Is applipnt blind as defined in IC 12-7-7-1(n) and IC 6-1.1-12-12(b)? Is applicant disa6led and unable to engage in any substantial gainful aaiviry
� as defined in IC 6-1J-12(d)? �
❑ Yes CHGo ❑ Yes ❑ No
Is the property used and occupied primariy for hisfier residence? Dces the applicanPs tazable gross income for the preceding calendar year
exceed 517,000?
�� es ❑No .(J(1 �w � Qp� ❑Yes L�No
Taxing d' riC Key number / Legal escription Record number Page number
`� � �$--��!-�-b-�-�., � �v ,
I/We certify under penalty of pery'ury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Signatu[a�6f applicant Signature of auNorized representative
X �
Addreu o applinnt Address of authorized representative