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APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
State Form a3710 epartm 8) i fl i'�
Prescribed by the Oepanment of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). e ' -
INSTRUCTIONS: OCT c �O�
To be filed in person or by mail with the County Auditor of the county where the property is located. l• O J C
Filing Dates: 1) Real Property:During the year for which the deduction is sought.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During GlyS Fore
March 31 of each year the individual wishes to obtain the deduction. )Aj
See reverse side for additional instructions and qualifications. G IBSO N COUNTY AUDITOR
Name of applicant(owner or contract bu/y�eer)
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Is applicant the sole legal or equita4 owner? If No,what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom:
❑Yes pNo
If name on record is different than that of applicant indicate below:
—
Name of contract seller
Address of contract seller(number and street city,state,and ZIP code) Is property in question:
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Is applicant blind as defined in IC 12-7-2-21(1)? Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)? t �
❑Yes S }'Yes ❑No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar year
exceed 517,000?
rigs 0 N ❑Yes ❑No
Taxing district Key number I Legal description Record number Page number
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IIWe 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 applicant Address of applicant (number and street,city,state,and ZIP code) -/ 1 c---"9-1/1. A '
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Signature of autcnaed representative Address of authorized representative (number and street city,state,and ZIP code)