Disabilty_Jines (2) APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
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=i - State Form 43710(R12/10-16)
S`j Prescribed by the Department of Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. try a t1,.1.
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:Form must be completed and signed by December 31 and filed or postmarked by the tqforinvAnur p.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property.DOThigith g tvielvel 2)mon • -
March 31 of each year the individual wishes to obtain the deduction. .
See reverse side for additional instructions and qualifications. CI H rl i d
Name of icant(owner or contract buyer) $B
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 whomc
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If name on record is different than that of applicant indicate below:
Name of contract sae,
Address of contract seller(number and street,city,state,and ZIP code) Is the 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)7 Is applicant disabled and unable to engage in any substantial gainful activity
as defined in IC 6-1.1-12-11(d)?
❑Yes es ❑No
Is the properly used and occupied unmanly for his/her residence? Does the applicants taxable gross income for the preceding calendar year
exceed$17,000?
es ❑No ❑Yes No
Taxing district Key number/Legal description 02i Record number(contract) Page number(contract)
'QvA\ncr '^ - 2b '1z-01-20I-0 cm. s3(o
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of ap. •-it Address of a pII ant (numler and street,city.state,and ZIP code)
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Signature of a •resentative Address of authorized rep - tative (number and street,city:state,and ZIP code)