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APPLICATION FOR BLIND OR
�°-e County ownshi Year
� d �: °,� DISABLED PERSON'S DEDUCTION
, '. :, FROM ASSESSED VALUATION
State Form 43710(1-90)
�. �'^" � Prescribed by the State Board of Tax Commissioners
Y 0 199"
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
county where the property is located during the 12 months before
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
Applicant �d ner or contract buyer)
QAJ
Is applicant the sole legal or If no, what
e wtable owner? interest?
� yes ❑ no
��,�
Name of contract
contract
Is applicant blind as defined in
IC 6-1.1-12-12(b
� yes no
�{-
exact
File Mark
�� �. r��
AUDITOR
If owned with someone other than
spouse, indicate with whom.
12-1-7-1(n) & Is the applicant disabled and unable to engage in any
subst ntial gainful activity as defined in IC 6-1.1-12-(d)?
�yes � no
Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
resid nce? preceding calendar year exceed $13,000?
� yes � no � yes �no
�L�
Taxing District Key Nu I Description Record No.
o O -op (� 3-
1' iJ W I 5- a- �O �• 0.2J Page 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 of Indiana and owner of the aforementioned property on March t, 19
Authorized Representative (by executed Power of
Attorney)
L f�,..-{� n. �4