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"'" APPLICATION FOR BLIND OR DISABLED PERSON'S
r����� DEDUCTION FROM ASSESSED VALUATION
Sta[e Fortn 43710 (R / 9-%)
'� � Prescribed by Ne State Boartl ot Tan Commissioners
,�alion contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILING:
To be /iled in person or by mail with the Counry Auditor o/ the county where the property is loca-
ted during the 12 months belore May i l 07 the year the deduction is to be elfective.
See reverse side (or additional instructions and qualilications.
Name of 2ppii t(owner or contracf buyerJ
,��e� �'. ,�-��
Is applicant the wle legal or equitable owner? If No, what is hisfier
,ffl'Yes ❑ No
name on record is difterent than that of applican
ame of contract seller
idress of contract seller
applicant blind as defined in IC 12-1-1-1(n) and
❑ Yes �No
Ne property used and occupied primarily. tor his
�'1'es ❑ No
�zmg districl �
�/CJ/ D �i
as
exceed
COUNTY TOWNSHIP YEAR
File
d . , .
�AY 0 6 IybO
. G,
�� �
v✓"� r` - hJu11 � ,
Gl85Gtd �OUr�TY . '
ned with someone other than spouse,
ate with whom
t tlisabletl and unable to engage in any substanlial gainful
in IC 6-1.7-12(d)? [�es ❑ No
tanabie gross income tor the
number
❑ Yes
year
I/We certi(y under penalty of perjury lhat lhe above and foregoing information is true and correct and that the applicant was a resi-
dent o( Indiana and owner'of the a(orementioned property on March 1, 19 _
Signature of authorized
idress of applicant p
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