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. W APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
Slate Form 43710(R9/9.08) �:�:� � i'�
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Prescribed by the Department of Lod Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). 1 ; F u him!. .-
INSTRUCTIONS:
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To be filed in person or by mail with the County Auditor of the county where the property is located. JUN 2 2015
Filing Dates: 1) Real Property:During the year for which the deduction is sought l
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During e twelve 12) fore
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications. CIBSON COUNTY AUDITOR
Name of applicant(owner or contract buys I
AIP
Is applicant the sole legal or equnauie owner? I No.what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
Yes ❑No
If name on record is different than that of applicant,indicate below:
Name of contract seller
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Address of contract seller(number and street.city,state.and ZIP code) Is the rty in question:
Real Property ❑ Annually Assessed
. Moble Flame(IC B-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial 'Ad activity
as defined in IC 6-1.1-.12-11(d)?
❑Yes ❑No Yes ❑No
Is the property used and occupied primarily fo is/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000? ,�,
Yes ❑No ❑yes pdNo
d Key number/Legal description 1 Record number Page number
Lent/en •
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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 1,20 .
Signature of app( Address of applicant (number and street,city,state,and ZIP code)
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Sig allure of authorized represent a Address of authorized representative (number and street,city,sate,and ZIP code)