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'u APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
1= DEDUCTION FROM ASSESSED VALUATION -TT 1J
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State Form 43710(R9/9-08)
Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b). OCT 10 ZOIJ File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property:During the year for which the deduction is sought. d�1 j:
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as c• • ;ur ir?thogIve(12)months before
March 31 of each year the individual wishes to obtain the deduction. G I BSON
See reverse side for additional instructions and qualifications.
Name of applicant/owner or contract buyer)
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H appficant the sole legal or equitable owneR If No,what is his/her exact share of interest? tl owned with someone other than spouse,
indicate with whom:
les ❑No
If name on record is different than that of applicant,indicate below-.
Name of contract seller
Address of contract seller(number and steel,city,state,and ZIP code) Is the property in question:
❑ Real Property ❑ Annually Assessed
Mottle Kane(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)?
. ❑Yes ❑No WI 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$17.000?
❑Yes 0 N ❑Yes (.610
Taxing district • Key number/Legal description Record number Page number
lazing
r-?/0—) 9-i9 _ /o/ - 060 /3 do? 0
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 .
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•:-um of applican Address of applicant (number and street,city,state,and ZIP )
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Signature of authorized :6-•'t alive Address of authorized representative (number and street,city,slate,and ZIP code)