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APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Form 43770 (R6 / 4-06)
Prescribed 6y the Department of Local Govemment Finance
COUNTY TOWNSFiIP YEAR
In�tion contained in this document is CONFIDENTIAL pursuant to IC �2-1-1-1(n) and IC 6-1.1-72-12(b). File Mark `� �•'��
i ucnoros: JUL 0 3 2007
To oe filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is to be effec ' '
2) Mo6ile Homes assessed under IC 6-1.1-7: During the 12 months before March 2 of each ye r �vid�vishes to 9
obtain tbe deduction. r_iacnti coL1NTY AUOITOR
See reverse side for additional instructions and ualificafions. �
Name of appl' nt owner or contract buyerJ Q
Is applicant the sole legal or equitable owner? I( No, what is ' er exact share of interest? If owned with someone oiher than spouse.
indicate with whom
❑ Yes ❑ No
If name on record is ditterent than that of appiicant, indipte bel
Name of contract seller
Address of contrad seller Is the property in questlon:
- ❑ Real Property ❑ MobOe Home (IC 61.1-7)
Is applicant blind as defined in IC 12-�-1-1(n) and IC 6-1.1-12-72(b)? Is applicant disabled and unable to engage in any substantial gainful activiry
as defined in IC 6-'1.7-12-1�(d)?
❑Yes ❑No ❑Yes ❑No
Is Ihe property used and ocwpied primarily for his/her residence? Does the appliwnt's taxable gross income (or the preceding wlendar year I
exceed 577,000?
❑ Yes ❑ No ❑ Yes ❑ No
Taxing disirict � Key number / Legal descrip��� ^� O� Record number Page number
/� (.i/h-(�jY� a�Y -��-/�{ -!00 - 9$9�-s�`lLZ-b �
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representative
` • '�
Address of applicant . . Address of authorized representative �
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