Disabilty_Patterson (2)X
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APPLICATION FOR BLIND OR DISABLED PERSON'S n i Yeaz
DEDUCTION FROM ASSESSED VALUATION
� , Sfate Form 43710 (R9 / 9-OB)
N Prascribed by ihe DepaAment of Local GovemmeM Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). �AN 2 9 Q��a�
INSTRUCTIONS:
To be filed in peisa► or 6y mait wifh the CowrtyAuditor of the aounly where the properiy is located. �•
Filing Dates: 1) Real Propeity: During the year for which the deduction is sought.
2) Mobile Nomes assessed under IC 6-9.1-7 or Manufactured Homes not assessed as R�Q��ii�it��t�6i�����xrths befwe
March 31 of each year the indnrtdual wishes to obtain the deduction_
See reverse side for additional inshuctions a� qualifications.
Name of applicant (owner or contract buyer)
V —
Is applicarri the sole legal or equitable owne(? H No, what is hisfher exad share of irrteresY? M owned with aomeone dher lhan spouse,
indicate wilh whom:
❑Yes ❑No
If name on record is dilferent than that of appliqnt indicate bebw:
Name of conhact seiler
Address � oontrad seller (nuunber and s6eet. city, state. a� Z!P code) Is Me property i� queslion:
� Real PropertY � Mnualy As�ssed
Mobde Horne (IC fr1.1-7)
Is applicani blind as defined in !C 12-7-2-21(1)? Is applicard disabled and unable to engage in arry subsfantial gain(ul adivity
as defined in IC 61.1-12-71(d)?
❑Yes ❑No �Yes ❑No
Is Ihe propeAy used a�d occupied primarily (or his/her residence? Does the applicanYs taxable gross income for the preceding cale�da� year
exceed $17.000?
Yes ❑ No ❑ Yes ❑ No
Taxin istrict
the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature of applicant Address of applicant (number and street, city, state, and ZlP code) ��� 7a
1 �v-J � � 4 7 J�1 . , � %�c� �e S� �• �oN ��
Signature of authorized rspresentative Address of aufhorized represeniative (number and street, city, state, and ZIP code)