Disabilty_Folkman '*' a•,,�Q APPLICATION FOR BLIND OR County
Township Year
e •". DISABLED PERSON'S DEDUCTION t p
?. , FROM ASSESSED VALUATION �F
State Form 43710(1-90) FILED
�" "" " Prescribed by the State Board of Tax Commissioners
WWII Fig Mar l
Instructions for filing:
To be filed in person or by mail with the County Auditor of the Ai• iii.-",--k
county where the property is located during the 12 months before AUDITOR
May 11 of the year the deduction is to be effective. See reverse
for additional qualifications and instructions.
Applicant (Owner or contract buyer( ,� xa
, k /� r, p Q//ern
Is applicant the sole legal or It no, what is his/her exact share of �/j If owned with someone other than
equitable owner? interest? spouse, indicate with whom.
'Q yes ❑ no
If name on record different than that of applicant, indicate below:
Name of contract seller: t1 ,/ � IC ��/
Z71 / �Q�.L7Q SI.C/Q .
Address of contract seller:
•
Is applicant blind as defined in IC 12.1.1.1(n) & Is the applicant disabled and unable to engage in any
IC 6-1.1-12-12(b)? substantial gainful activity as defined in IC 6-1.1-12-(d)?
O yes ❑ no O yes ❑ no
•s the property used and occupied primarily for his/her Does the applicant's taxable gross income for the
residence? • preceding calendar year exceed $13,000?
`ayes ❑ no *7)06 t ❑ yes ❑ no
Taxing District Key Number/Legal D scription Record No.
A o7�-//- /;-/o 660. O o21
_ + Page No:
I/We certify under penalt lot 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, 19
Signat - Authorized Representative (by executed Power of
'/ 1 / Attorney)
rAdress of Applicant Address of Representative
x e/ - J7S' _ Peiu cc: '0 / .
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