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- '. APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
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State Form 43710(R12/10-16)
1 Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. File Mark
INSTRUCTIONS:
To be filed in poison or by mail with the County Auditor of the county where the property is located. T Tp g�,1
Filing Dates: 1) Real Property Form must be completed and signed by December 31 and filed or postmarked by th n lanuaT�S.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Properly: nng.the-(welveM(12)tutu s before
March 31 of each year the individual wishes to obtain the deduction. -1
See reverse side for additional instructions and qualifications. S E P 1 9 2018
Name of applicant(owner or contract buyer)
H applicant the sole legal or equitable owner? If No,what is his/her exact share of interest? If owned of teone'othis$ian spouse;'•T
indicate with whom:
EPes No
If name on record is different than that of applicant indicate below:
Name of contract seller
•
Address of conted d.affee;-city; e,as P ode) Is the p in question:
D- ealProperty ❑ 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)?
CI Yes iitt ❑Yes No
Is the property used and occupied primarily for his/her residence? Does the applicant's taxable gross income for the preceding calendar y
exceed 517,000?
C+}'Yes ❑No ❑Yes No
Tatting district Key number I Legal description Record number(contract) Page number(contract)
PryrNc Gaon �t9 la 1 c n -oCr2 .1494 -® 38.
UWe certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of applicant (number and street,city,state,and ZIP code)
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Signature of authorized representative Address of authorized representative (number and skeet,city:stale,and ZIP code)
