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�,,,,� APPLICATION FOR BLIND OR
d .�: °� DISABLED PERSON'S DEDUCTION
. --' FROM ASSESSED VALUATION
� �.,_ ,a,.: ,.� State Form 43710(1-90)
Prescribed by the State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the
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.
County Township Year
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AUDITOR�
A licant (Ow er or con a�t buyer) M
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Is applica the sole legal or If , what is his/her exact share of If owned with someone other than
eqwta le 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 unatile to engage in any
IC 6-1.1-12-12(b)? substantial gainful activ'ity`�s"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
residence? preceding calendar year exceed $13,000?
� yes � no � yes � no
Taxing District Key Number/Legal Description Record No.
�w 0..���i -00 � Page No.
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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 .
Signature Authorized Representative (by executed Power of
\ Attorney) �
Addres of Applicant Address of Representative �