Disabilty_Sporei_ : --!"
_ iJ��-
"''"° APPLICATION FOR BLIND OR DISABLED PERSON'S
!�► . - � DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43770 (R / 9-96)
�' �� Presaibed by Ihe S�ate Board ol Tax Commissioners
tion tontained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-7.1-12-12(b).
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the CountyAuditor ol the county where the property is loca-
ted during the 12 months be%re May 77 0l the year the deduction is to be eflective.
See reverse side /or additional instructions and qualilirations. �(l 1�
r—
Name of applicant lowner or contraa buv d __
or
❑ Yes �'FJo
name on record is ditterent than that of applicanL
contract
No, wha[ is his/her exad share
below
Is appiicant blind as defined in IC 12-1-1-1(n) and /ICC- 1.7-12-
❑ Yes , Id'No
in IC 6-1.1-12(d)?
COUNTY TOWNSHIP YLwR
�' �q
�J ileM2rk y i,
� ���.��:� �
Id�
M:1Y 10 199�
- /� . �
`.� y ,:
. // ,•,/
� . - ..-`� 1 �' ;�c-�-�t�-c_
— '�'-
:.� .
rned with someone other th spous4,(
ata+�yth whom \J
n - '
MAY 0 3 2001
�
O No
prunariry_ ror nfsiher resltlence? Does the applicani's ta�cable g�oss income for the precedin9 calendar year
�. �a-o'1- 3 o$o�:i°•°i s�.o'- 7�.Q
Y S oNO a �1 _f�bl���., �S .��
. �` ` ��'pl•��' 3� rd mber Pa9enumber
_ � `� .
I/We certity under penalty of perjur�-(h'dt th`e a�ove and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'o( the aforementioned property on March 1, 19 _
iature of applicaN Signature ot authorized representative @v executed Power o/Atfomevl
of
d