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� (� MJ�� APPLICATION FOR BUND OR DISABLEO PERSON'S couNTr rowNSHiP reaR
3. DEDUCTION FROM ASSESSED VALUATION
�< j Slate Fortn 43710 (R7 / 5-06)
Resaibed b y the D e p ar tr n mi d L o c al G w e i n m e n t F in a n c e -
nfwma[ion contained in this documen� is CONFIDENTIAL pursuan� to IC 72-1-1-1(n) and IC 6-7.7-12-72(b�. Fi a
,NSTRUCTIONS:
To be (iled in person or by mail with the Counly Auditor o! fhe county where lhe property is localed. �^ D U 7
Filing Dates: 1) Real Property: Dunng the 12 months before June 7] of the year the deduction is to be e, GRhre. ZOOS
2) Mobile Homes assessed unde� IC 6-7.7-7: Dunng the 12 mon(hs belore March 2 of each�ear (he individual wishes (o
obtain the deduction. �� ��
See reverse side for additional insWcfions and nuaGfiran�.,�
of applicant (owner or conVact buyer)
applirant fhe sole legal or
name on record is diHeren
ame of wnUact se0er
ddress of convact sNler
owner?
❑ Yes O No I
Ihan Ihat of applirant, indicate
(�
Is applicant blind as defined in IC 12-1-1-1(n)
❑ Yes
property
for his/her
❑ No
exaU share
It owned with someone other than spouse,
indicate with whom
Is the property in queslion:
� O Real Property ❑ Mobile Home pC 67.
Is appliwnt disabled and unable to engage in any substantial gainful activi
as defined in IC 61.1-12-N(d)?
�yes ❑ No
Does the applicani's taxable gross income (or the preceding wlendar year
exceed 517.000?
a�-1 r-o8-�0o-7o�F.��.oa�
❑ No
iae number
I/VJe ceAify under penalty of perjury that the above and foregoing infortnation is true and covect and that the applicant was a resident
of Indiana and owner of the aforementioned properry on March 1, 20 _
of
appliwnt
� .
t �a �.
.
of
representative
: �