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"'' � APPLICATION FOR BLIND OR DISABLED PERSON'S courrrv
, 4 DEDUCTION FROM ASSESSED VALUATION
`�+ State Form 43770 (R / 9-%)
� Preurihed by Ne State Board of Taz Cammissioners
I�ation contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-7 (n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the property is loca-
ted during the 12 months belore May 77 of the year the deduction is to be el/ective.
See reverse side loi additional inshuctions and qualilications. �
i
Name of aoolicam lowner or contracl buved .,..
the sole legal or equitable
name on record is
contract
Address ot contract seller
as
P�aPertY
❑ No
❑ Yes ❑ No
❑ No
It No, what is his/her exad
as
Does the applicanYs
exceed $17,000?
r�,A
' � N A a..� _Q_
MAY p 8 1997
` _:J�ONC�OU��iI n�_�iTOR
I with someone other than spouse,
with whom
I and unable to engage iR a-ny s�
�-�2(d)? `�Yes
/
gross
❑ Yes
O No
year
Taxmg tllstricl Key number / Legal description I Record number Page number
f ,--- - ?
1��� .' �i��-'--���s�-l17� t
I/We certify under penalty of 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, 19
Signature of applicant Signature of authorized representative (by executed Power olAttomey)
;3flt Atltlre55 ot authoflzEtl repre5entatiVe
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