Disabilty_Dilbeck„
°"Aa APPLICATION FOR BLIND OR DISABLED PERSON'S
r! ;_ � DEDUCTION FROM ASSESSED VALUATION
� State Form a3710 (R / 9-96)
'' ��� � Prescribetl by the State Boartl of Tav Commissioners
.ortnation contained in this document is CONFIDENTIAL pursuant to IC 12-7-7-1(n) and IC 6-1.7-12-72(b).
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the Counry Auditor o/ the couniy where the property is loca-
ted du�ing the 12 months before May 11 0! the year the deduction is to be effective.
See reverse side for additional instructions and qualilications.
or contrad
or
—�Yes ❑ No I
If name on record is diHerent than thai of applicant, indicate below
comran
Address of contraci seller
exact
OCT 2 4 1998
GIBSQY
someone oiher than spouse,
whom
applicant blind as defined in IC 12-1-1-1(n) and IC .1-72-12(b)? Is applicant disabled and unable to engage in"any stantial gainful activiry
as defined in IC 6-t.t-72(d)? es ❑ No
❑ Yes
the properry used and occupied prima � for his�her residence? Does the applicanYS ta�cable gross income for the preceding calendar r
exceed Sn,000?
IYes ❑ No ❑ Yes o
zing di tric � Key number / Legat descripiion Record number age number
—O��p� l—
1/We certify under penalty ot perjury that ihe above and foregoing iniormation is true and correct and that the applicant was a resi-
dent of Indiana and owner of Ihe aforementioned property on March 1, 19 �
of applicant
l��1
/� �
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