Disabilty_Cundiff`" � APPLICATION FOR BLIND OR DISABLED PERSON'S
�� DEDUCTION FROM ASSESSED VALUATION
` �` Stale Fortn 43770 (R7l 5-OG)
PresviM.�d bY �e Deparimrnt d locil Gwunment Finance
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�niormation contained in this documeN is CONFIDENTIAL pursuant to IC 12d-1-1(n� and IC 6-7.1-12-12(b�. QC��� gaQ(j�)
NSTRUCTIONS:
To be /iled in pe�son or by mail with the Counly Auditor of the county where fhe property is located.
Filing Dales: iJ Real Property: Dunng !he 12 months before June ll ot the year lhe deduction is to be effective. �' ��
2J Mobile Homes assessed under IC 6-7. 7-7: During the 72 months betore March 2 of ea6lil�hh6fdHµFN��1,y�R�to
obtain the deducfion.
�
See reverse side for additi
Name of applicary�o,A�ner o�
appliwnt
�/ ❑,�€s ❑ r,o �
name on record is diBerent than that of applicant, indicate below
ame of contract seller
]dress of conUacl seller
applirant blind as defined in IC 72-1-1-7(n) antl IC 6-1.1-12-12(t
' �Yes �No
o�ooem
❑ No
residence?
�
It mvnetl wlth someone other than spouse,
indiwte with whom
Is the property in queslian:
�2ea� Property ❑ Mobtle Home QC &1.1-7)
able to engage in any wbstanlial gain(ul activiry
(d)?
❑ Yes ❑ No
� gmss income for the preceding calendar year
❑ Yes ❑ No
ecord number Page number
I/We certify under penalty of"perjnry 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
%
of
�
r��1
representative