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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
❑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