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APPLICATION FOR BLIND OR
DISABLED PERSON'S DEDUCTION
FROM ASSESSED VALUATION
State Form 43710(1-90)
Prescribed by the State Board of Tax Commissioners
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 or contract
equit le owner?
yes � no
name on
Name of contract seller:
Address of contract seller:
is appucant ouno as
IC 6-t.t-12-12(b)?
� yes � no
or Iir no, wn
interest?
12-1-1-1
exact
%>�i _
r0 B
If owned with someone other than
spouse, indicate with whom.
Is the applicant disabled and unable to engage in any
substan ial gainful activity as defined in IC 6-1.1-t2-(d)?
�es � no
Is the property used and occupied primarily for his/her poes the appiicanYs taxable gross income for the
reside e? preceding calendar year exceed $13,000?
�yes � no � yes e no
Tauing District Key Number/Legal Description Record No.
P/aroK.fr j LJp. ��� - 03%5/- op Page No.
I/VJe certify under penalty of perjury that the above and foregoing information is true and correct and that the appiicant
was a resident of Indiana and owner of the aforementioned property on March 1, 19 ��P .
Signature
> of Applicant
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Authorized
Attorney)
(by executed
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