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> "" APPLICATION FOR BLIND OR DISABLED PERSON'S
�, • •. ; DEDUCTION FROM ASSESSED VALUATION
S ; State Fortn 43710 (R614-0d)
'•�• Prescdbed by the Depanment of Local Govemment Finance
COUNTY I TOWNSHIP I YEAR
Ir` �^�ation contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and �C 6-1.1-12-12(b). �������
l�UCTIOMS:
To be filed in person or by mail with the CountyAuditor of the county where the propeRy is located.
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 of the year the deduction is to be effecN'vLe q� 'nn�
2) Mo6ile Homes assessed under IC 6-1.1-7: During the ]2 months be%re March 2 of each ye�r�heYn�vld(IBPwishes to
obtain fhe deduction. -
or
Is applicant ihe sde,JagerS�/table owner? If No, what is his/her exact
J
❑ Yes ❑ No
If name on rewrd is difterent �han that of applicant, indicate below
Name
conUacl
Is applicant blind as defined in IC 12-1-1-1(n) and IC Fj�l.1-72-72(b)?
❑ Yes
Is the property used and occupied prim
disVict
d6r hislher residence? Doe
exa
❑ No
Key number / Legal description
�� ' 1 i A
GIBSON
I vrith someone other than spouse,
with whom
Is the property in Question:
❑ Real Property ❑ M
! disabled and unable lo engage in any su �
in IC 6-7 J-� 2-11(d)?
Yes
pplicanPs taxable gross income for the prec
',000?
. ❑ Yes
(IC 67.1-7)
❑ No
ing calendar ar
0
I/We certiy under penalty of perjury thal the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of lhe aforementioned property on March 1, 20 _
of authorized representative
of auihorized representative