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APPLICATION FOR BLIND OR DISABLED PERSON'S N t SHIP YEAR
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DEDUCTION FROM ASSESSED VALUATION � ou� �f
State Form 43710(R12/10-16)
Prescribed by the Department of Local Government Finance
APR 1 1 2013 File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the properly is located.
Filing Dates: 1) Real Property:Form must be completed and signed by December 31 and filedg)gg(r}w1e erRalY 5.
2) Mobile Homes assessed under IC 6-1.1-7 or Manufactured Homes not assessed as Real Property:During the twelve(12)months before
March 31 of each year the individual wishes to obtain the deduction.
See reverse side for additional instructions and qualifications.
Name of applicant(owner or contract buyer)
Is applicant the sole or 'table owner? If No,what is his/her exact share of interest? - If owned with someone other than spouse,
indicate with whom:
❑Yes ❑No
If name on record is different than that of applicant,indicate below
Name of contract seller
Address of contract seller(nun'ber and street,city,state,and ZIP code) Is the property in question:
- keal Property ❑ AnnuallyAssessed
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)?
❑Yes .-fPo $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 517,000?
Yes ❑No ❑Yes ❑No
Taxing district Key number I Legal description Record number(contract) Page number(contract)
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INVe certify under penalty of perjury that the above and foregoing information is true and correct.
Ktignato 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 street,city,state,and ZIP code)