Disabilty_Corsentino�� APPLICATION FOR BLIND OR DISABLEO PERSON'S
DEDUCTION FROM ASSESSED VAIUATION
State Fortn 43710 (R715�06)
�
Prewibed by �he Departmart of �ocal Govemment Finance
COUN T YEAR
i
�n(orma�ion contained in this document is CONFIDENTIAL pursuant m IC 72-7-7-7(n) and IC 6-1.7-12-12(b). QUG 1���e�
NSTRUCTIONS:
To be (iled in person or by mail with the County Auditor o! the counry where Ihe property is located. '�j) �
Filing Dafes: i) Real Property: During the 12 months before June 11 of fhe year the deduction is to be eN'ecF� �'
2) Mobile Homes assessed under IC 6-1.7J: Ou�ing the 12 months be/ore Ma�ch 2��B�yw(f�fpd�hes to
obfain the deduction.
See reverse side for additional inst�uctions and ualificalions.
Name of aoolicant lowner or conbac( bwer) ,.
is appucant Ne sole legal or equi[able owner? If No, what is
❑ Yes ❑ No
If name on record is diBerent Ihan Ihal of applicant, indicate below
Name of conUact seller
Address of wnUact seller
Is applicant blind as defined in IC 12-1-1-1(n) and IC 6-7.7-
❑ Yes ❑ No
the property used and xwpied primarily (or his
❑ Yes ❑ No
Key number /
J
a�-�� 6-n L
exaU share oi interest? I( owned with someone other than spouse,
indicate vnth whom
as
Does
Is the property in questlon:
QR"eal Property ❑ NbbOe Home (IC 67.1-
1 disabled and unable to engage in any substantial gainful activity
in IC 6-1.1-12-11(d)?
�s ❑ No
pplicanCs taxable gmss income or the preceding calendar year
'.000?
❑ Yes ,�?lo
Rewrd number Paqe number
-,�j -cr�3 oFr� -o
I/We certify un�'er penalty of perjury that ihe above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
appliwnt /-]
� A' !C �
waress o� appucam , Address of auUiorized
�l �� / ,r/_ i. ..-� `1 i7 _ _/% /
representative