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��"'°"AV APPLICATION FOR BLIND OR DISABLED PERSON'S courm TOWNSHIP YEAR
.g : DEDUCTION FROM ASSESSED VALUATION
� � State Form 43710 (R / 9-96)
S � Presttibed by the State Boartl ot Taz Commissioners
Wa
FileAAark
Intormation contained in this dowment is CONFIDENTIAL pursuant to IC 12-7-7-1(n) and IC 6-7.1-72-72(b). ,-...� ���--q
INS7RUCTIONS FOR FILING: �
3
'�.-�'
To be liled in person c,- by mail with the County Auditor of the counry where the property is loca-�� �!'•'
ted during the 72 months be%re May 77 0/ the year the deduction is to be eBective.
See reverse side (or additional instructions and qualifrcations. � P R Q 4�Q�O
o� contract
Is applicant the lole legal or
exact
❑ Yes ❑ No �
tl name on record is difterent than that of applicant, indicate below
Name of contract seller
Address of contract seller
Is applicant blind as detined in IC 12-t 7 1 d IC 6-1.1-12-12(b)? Is ap{
as de
Is the properry used and occupi d pnm ' for his/her residence? Does
� ezceE
_, es ❑ No
Tazi istrict Key number / Le9aLQ29cr �
y t=/
�= Q _ -1. . ✓1 .t11��n �.[\�-! �
in IC 61.7-12(d)?
spouse,
with whom
ro engage In any stantial g�
es ❑ No
e appiicanfs t�able gross income for the preceding calenda
$7 7,000? � �
❑ Yes LyrGo
Record number Page number
_W
I/We certify under penalty oi perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 79 _
represeNative (by executed
authorized representative