Disabilty_Duran e R -,t APPLICATION FOR BLIND OR DISABLED PERSON'S � �If�^��� �k YEAR
DEDUCTION FROM ASSESSED VALUATION
j State Form 43710(R11 1 11-15)
Prescribed by the Department of Local Government Finance
.iat' t
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. -
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. 5��
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filed or postman fWej i u l A
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During he e mo 1hhs before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
Pedro G Duran
Is applicant the sole legal or equitable owner? If 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
Address of contract seller(number and street,city,state,and ZIP code) Is the 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)?
4
❑Yes ID No O Yes ❑No p
Is the property used and occupied primarily for hismer residence? Does the applicant's taxable gross income for the preceding calendar year
exceed$17,000?
❑Yes ❑No ❑Yes ❑No
Taxing• district Key number/Legal description Record number(contract) Page number(contract)
4�0,771ornertc\ ;(c -l7-IC.-3o0-00 .D(o-CP4
INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of..•Kant Address of applicant (number and street,city,state,and ZIP code)
X l4 4 t2� 73247 S lost/ W, 3wensvil(e , /N q76
Signature of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)