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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
APPLICATION FOR BLIND OR DISABLED PERSONS DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R12 / 10-16)
Prescribed by the Department of Local Government Finance
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Form must be completed and signed by December 31 and filed 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.
for additional instructions and qualifications.
Name of applicant (Last, First)
Is applicant the sole legal or equitable owner?
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:
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)?
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?
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)
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