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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
APPLICATION FOR BLIND OR DISABLED PERSON’S DEDUCTION FROM ASSESSED VALUATION
COUNTY
TOWNSHIP
YEAR
State Form 43710 (R13 / 1-20)
Prescribed by the Department of Local Government Finance
File Mark
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 and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the property taxes are first due and payable.
Special Instructions
Reviewed
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for additional instructions and qualifications.
Name of applicant (Last, First)
Phone
Email
Is applicant the sole legal or equitable owner?
YES
NO
If No, what is his/her exact share of interest?
If owned with someone other than spouse, indicate with whom:
If name on record is different than that of applicant, indicate below:
Name of contract seller
Address of contract seller (number and street, city, state, and ZIP code)
Is the property 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)?
YES
NO
Is applicant disabled and unable to engage in any substantial gainful activity as defined in IC 6-1.1-12-11(d)?
YES
NO
Is the property used and occupied primarily for his/her residence?
YES
NO
Does the applicant's taxable gross income for the preceding calendar year exceed $17,000?
YES
NO
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
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Address of applicant (number and street, city, state, and ZIP code)
Signature of authorized representative
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Address of authorized representative (number and street, city, state, and ZIP code)
Attach Document (PDF, JPG, PNG, GIF, TIFF Only)
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