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��„n APPLICATION FO BLI �, . A
�`' °a� DISABLED PERSON'S DEDUCTI; � ' , � ' Y
. FROM ASSESSED VALUATION '
. � State Form 43710(1-90) �' � ,�� ,
'� '°�• "�• prescribed by the State Board of Tax U,. .mi�� ,,�F� , "`
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Instructions for filing: J �
To be filed in person or by mail with the County Auditpr of the ' /
county where the property is located during the 12 mdnths befc,re
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions. ,
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�AUDITOR ° �
Year '
Applicant (Owner or contract buyer) •
Is applicant the sole legal or If no, what is hi her exaci share of If owned with someone other than
equitable owner? interest? spouse, indicate with whom.
�es � no
If name on record different than that of applicant, indicate below:
Name of contract seller:
Address of contract seller:
Is applicant blind as defined in IC 12-1-1-1(n) & Is the applicant disabled and unable to engage in any
IC 6-1.1-12-t2(b)? substa gainful activity as defined in IC 6-1.t-12-(d)?
� yes � no yes � no
Is the property used and occupied primarily for his/her poes the applicant's taxable gross income for the
reside e? preceding calenda ar exceed $13,000?
yes � no � yes no
Taxing District mber/ e cri � Record No.
OPage No.
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant
was a resident oi Indiana and owner of the aforementioned property on March 1, 19 .
Si nature Authorized Representative (by executed Power of
� Attorney)
'1^ti � �-...1 '
ddress of Ap nt Address of Representative
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