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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
Stale Form a3710 (R4 / 70-01)
Prescribe0 by Ne Departmen[ of Loral Govemment Finance
COUNTY TOWNSHIP YEAR
� � '�
��mation contained in this dowment is CONFIDENTIAL pursuant to IC 12-1-1-7 (n) and IC 6-1.1-12-12(b). � F I� a
RUCTIONS: ZOOZ
To 6e �led in person or 6y mail with the County Auditor o( the county whe2 the prope�ty is located. F E B 1 9
Filing Dates: 1) Rea/ Properfy: Dunng the 12 months befwe May 11 0/ the yea� the deduction is to e ef(ective. �
2) Mobile Homes assessedLnder IC 6-1.1-7: Between January 15 and March 31 of t year t e d�du ' n is t e ec6ve.
See ieverse side for additional instructions and qualifications. ��ggpN COU• "°. ���170R
Name of applicant (owner or contracf buyed
appucant che soie iegai or
name on record is differen
ame of contract seller
jdress of contrect seller
aoulipnt blind as defined
ezact
❑Yes ❑No
that ot applicant, indicate below
If owned with someone other than spouse,
indicate with whom
property
❑ Real PropeAy � Mobile Home
IC 72-7-7-1(n) and IC 6-7.1-12-72(b)? Is applicant disabied and unable to engage in any substantial gain
as defined in IC 67.1-72(d)?
❑ Yes �o . � Yes ❑ No
ied primarity tor hisRier residence? � Does Ne applicant's taxable gross income for the preceding calen
exceed S7
�es ❑ No
❑ Yes L�'No
Page numh
Fr1.1-�
year
I/We certify under penalty of perjury that lhe above and foregoing information is true and wrred and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20��
Signature of authorized representative
of authorized reDresenWtive