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,�'""'> APPUCATION FOR BLIND OR DISABLED PERSON'S cour+TV TOWNSHIP � YEAR
� DEDUCTION FROM ASSESSED VALUATION
�� State Porm 43710 (R4 / 70-07)
S:'� Prescnbed by Ne Department ol Local Govemment Finance
�ation contained in this document is CONFIDENTIAL pursuant to IC 12-7-1-1(n) and IC 6-1.1-12-12(b). File Mark
RUCTIONS: �� 7j 'p"
_ To be filed in person or 6y mail viith fhe County Auditor of the county where the property is located.� p ��
t
Filing Dates: 1) Real Property: During the 12 months before May 11 oI the year the deduction is�to be�eflec�e
2) Mobile Homes assessedLnderlC 6-1.1-7: Between January 15 and March 31 of the yr �r�the�d�ed�ut� is to 6e eflective.
See reverse side for additional instructions and qualifications. .. 11 ^ UL
.
or
If No,
❑ Yes ❑ No I
If name on record is difrerent than that of applicant, indicate below
Name ot coniract seller
as
the property
❑ Yes ❑
❑ No
share of interest?
/l ...._..,_.. ��. _... .� �.,.�_.,,... i
If owned with someone other than spouse,
indicate with whom
Is Ihe pr m question: " : '-�
eal Property ❑ Mobile Home,pC 61.1-�
1-72-12(b)? Is applicant disabled and unable to engage in any substa tial gainful activiry
as defined in IC 6-1.7-12(d)? -
- - -. es. .. .❑ No
�idence? Does the applicanYs taxable gross-inwme for Ne preceding calendar y
lexceed 517,000? . �
❑ Yes o
com numoer rage numner •�
I/We certify under penalty of perjury that the above and foregoing information is true and corred and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _ � � �
�
representative