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APPLICATION FOR BLIND OR
DISABLED PERSON'S DEDUCTION
FROM ASSESSED VALUATION
State Form 43710(1-90)
Prescribed bythe State Board of Tax
Commissioners
County Township
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Key�-�
"'°" File Mark
Instructions for filing: ��. Ay �t, _�, _
To be filed in person or by mail with the County Auditor of the AUDITOR `�
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.
Year
�
y
Applicant ( r or c ntract b yer) �
Is applicant the sole legal or If , what is his/her exact share of If owned with someone other than
equita owner? interest? spouse, indicate with whom.
yes � no
If name on record different than that of applicant, indicate below:
Name of contract seller:
Address of contract seller:
Is applicant blind as defined in IC 12-1-1-1(n) & Is the applicant disabled and unable to engage in any
IC 6-7.1-72-12(b)? substantial gainful activity as defined in IC 6-1.1-12-(d)?
� yes � no � yes no
Is the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
reside ? preceding calend r exceed $13,000?
yes � no � yes no
Taxing District Key Number/Legal Description Record No.
00 -o0 5a5 Page No.
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, 19
Signatu a Authorized Representative (by executed Power of
Attomey) , �,
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Addre of Applican Address of Representative