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��,,,,�4 APPLICATION FOR BLIND OR County
d ,� DISABLED PERSON'S DEDUCTION
=: --- '; FROM ASSESSED VALUATION
, 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.
Township
��R jag v- n
1994
Year
�., ,� s�
AUDITOR�'�
Appiicant (Own r or contract buye •
Gl.
Is applicant the sole legal or f no, what is his/her exact share of If owned with someone other than
e uitable owner? interest? spouse, indicate with whom.
� yes ❑ no
If name on re rd differ�ent than that��plicant, indicate below: .
Name of contract s r.
Address of contract seller:
Is applicant blind as defined in IC 72-t-1-1(n) & Is the applicant disabled and unable to engage in any
IC 6❑-1.1-12-12(t�? subst�ntial gaf❑nful activity as defined in IC 6-1.1-12-(d)?
yes ��( no lR� yes no
s the property used and occupied primarily for his/her poes the applicanYs taxable gross income for the
re dence? prec ding calendar year exceed $13,000?
� yes � no � yes � no
d C�
Taxing District Ke Number/Legal Des ri tion Record No.
. ��l- aOF��s�-c�8 � c�.
S t C- I- � Page No.
0
I/We certify und r enalty of perjury that the above and foregoing information is true and correct and that the applicant
was a resident o ndiana and owner of the aforementioned property on March t, 19
ignature Authorized Representative (by executed Power of
Attorney)
ddre�of Applicant � yp Address of Representative
.