Disabilty_Lloyd�n„� APPLICATION FOR BLIND OR
d�d+.. �4 DISABLED PERSOMS DEDUCTION
. FROM ASSESSED VALUATION
S3ate Form 43710(1-90)
�� �'°`•`'"�� prescribed by the State Board of�
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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 (Owner o contr r
Is applicant sol or If no, wh
equita owner? interest?
yes � no
If name on record different an t f a li
Name of contract seller:
Address oi contract seller:
Is applicant blind as
IC 6-1.1-12-12(b)?
� yes �
12-1-1-1(N &
Is the prope sed and occupied primarily for his/her
reside
yes � no
inq District Kev Number/La�al
;� .
�� �� .
Township
1�Year
���y .��
% � File Mark' f
n c.ea q �`1.`1:7
� ,
� DITOR��
It ownetl with someone othe
spouse, indicate with whom.
ippli tlisabied antl unabie to engage in any
I gainful activity as defined in IC 6-1.1-12-(d)?
yes � no
Does the applicanYs
preceding calendar �
� yes no
cs income for the
$13,000?
No.
I l �../0 - C�-�'' I" r° �,.",—� �� _,. �•—t•c�,_.•,,��h '
IlWe 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 1, 19 .
Signature
4ddress of Aoolic�nt (�, 0� B oX P9 "
lU3 W. �,;,i - . p0.rau.p, a �v
yab6G
Authorized Representative (by executed Power of
Attorney)