Disabilty_Daumr����°"A APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
�� State Form 43770 (Fi / 9-%)
l Prescribed by ihe State Boartl ot Tax Commissioners
I tlon contained in this document is CONFIDENTIAL pursuant to IC 12-1-1-1(n) and IC 6-1.1-12-12(b).
INSTRUCTIONS FOR FILINC3:
To be /iled in person or by mail with the County Audito� ol the county where the properry is loca-
ted during the 12 months belore May 11 01 the year the deduction is to be ellective.
See reverse side Ior additional instructions and quali/ications.
or contract
the sole legal6r equitable owner?
tl name on record is different than
contract
ot contract seiler
25
P�oPe�Y
❑ No
If No, what is his/her
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;iw�i:' 4i w'i � -
( ��., i�;
APR � � 1997
G!BSON
If ownetl with someone other Ihan spouse,
indicate wiN whom
G iz-t-t-t(n) antl IG El.t-72-12(b)'? Is applfcant tlfsabletl antl un3ble to engage in any s stanlial gainful activif
as defined in IC E7.1-12(d)? es � No
❑ Yes �
ed prima'ly.for his/her residence? Does the applicanYS taxable gross income for the preceding caiendar year
exceed $77,000? — /
Yes ❑ No ❑ Yes L.1N6
Key number / Legal description
T�n �r�S =��
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Record number
,
I/We certify under p Ity oi perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner'of the aforementioned property on March 1, 19 _
iature of applicant - Signature of authorized representative (by executed Powe� olAttomey)
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