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'':0•'1-'4. APPLICATION FOR CREDIT AGAINST PROPERTY COUNTY T TOWNSHIP YEAR
TAXES FOR BLIND OR DISABLED PERSON -
State Form 43710 (R15/ 7-25) -4)(41\ ,yl
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-`.s. Prescribed by the Department of Local Government Finance L)tiatA�
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Instructions: To be filed in person or by mail with the county auditor of the county where the property is located.
Filing Date: Form must be completed, signed, and filed by January 15 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Name of Applicant(owner or contract buyer)
If Owned with Someone Other than Spouse, Indicate with Whom
Q es ❑ No
If Name on Record is Different than that of Applicant, Indicate Below:
Name of Contract Seller Address of Contract Seller(number and street, city, slate, and ZIP code)
Is the Property in Question. Is Applicant Blind (as defined in IC 12-7-2-21(1))?
Real Property ❑ Mobile Home (IC 6-1.1-7) EYes JN
Is Applicant Disabled and Unable to Engage in Any Substantial Gainful Activity? Is the Property Used and Occupied Primarily for His/Her Residence?
❑Yes ❑ No es ❑ No
Taxing District Key Number/ Legal Description Record Number(contract) ' Page Number(contract)
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I/We 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 Authonzed Representative (number and street city. state, and ZIP code)
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RECEIPT FOR APPLICATION FOR CREDIT FOR BLIND 1 DISABLED PERSONS
Name of Applicant Date Filed (month, day, year)
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Name of Contract Seller
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Taxing District JAN 15 2026
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Key Number I Legal Description r
C; .0_ .- 1 D �^� lc a _ rap . .0 OQ ciBON COUNTY AUDITOR
Signature of County Auditor ` Date Signed (month, day, year)
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10 Benefit Verification Letter
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