Disabilty_Byrns-Kirby n,3 APPLICATION FOR BLIND OR DISABLED PERSON'S \ COUNTY TOWNSHIP YEAR
., DEDUCTION FROM ASSESSED VALUATION
a .T'� ': State Form 43710(R12/10-16) C\l
:
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 person or by mail with the CountyAuditor of the county where the prope is loc t
Filing Dates: 1) Real Property:Form must be completed and signed by Decembe t ed or postmarked by the following January 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)
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Is applicant the sole legal or equitable owner4� If o,what is his/her exact share of interest? ) If owned with someone other than spouse,
indicate with whom:
Flan‘ ❑No
If name on record is different than that of applicant,indicate below:
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Name of contract seller
et
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Address of contract seller(number and street city,state,and ZIP code) Is the props i �� h
❑ Real Pr kg°❑ AnnuallyAssessed
ete 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)?
❑Yeso es ❑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?
es ❑No ❑Yes MI gr.
Taxing district Key number/Legal description Record number(contract) Page number(contract)
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
Signature of applicant Address of appli�t(number and street,city,state,and ZIP code)
Signature of authorized repr tative L Address of authorized representative (number and street,city,state,and ZIP code)
review your case again and consider any new facts you have. A person who
did not make the first decision will decide your case.
• You have 60 days to ask for an appeal.
• The 60 days start the day after you receive this letter. We assume you
got this letter 5 days after the date on it unless you show us that you
did not get it within the 5-day period.
• You must have a good reason if you wait more than 60 days to ask for
an appeal.
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