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APPLICATION FOR BLIND OR DISABLED PERSON'S DEDUCTION FROM ASSESSED VALUATION
State Form 43710 (R9 / 9-08) Prescribed by the Department of Local Government Finance

COUNTY

TOWNSHIP

YEAR

Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-12(b).

File Mark

INSTRUCTIONS: 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: During the year for which the deduction is sought. 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 legal or equitable 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 (number and street, city, state, and ZIP code)

Is the property in question:

Real Property
Is applicant blind as defined in IC 12-7-2-21(1)?

Annually Assessed Mobile Home (IC 6-1.1-7)

Is applicant disabled and unable to engage in any substantial gainful activity as defined in IC 6-1.1-12-11(d)?

Yes

No

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 $17,000?

Yes
T axing district

No
Key number / Legal description Record number

Yes

No
Page number

I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident of Indiana and owner of the aforementioned property on March 1, 20 _____.
Signature of applicant Address of applicant (number and street, city, state, and ZIP code)

Signature of authorized representative

Address of authorized representative (number and street, city, state, and ZIP code)

RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND / DISABLED PERSONS
Name of applicant Date filed (month, day, year)

Name of contract seller

Taxing district

Key number / legal description

Signature of County Auditor

Date signed (month, day, year)

INSTRUCTIONS AND QUALIFICATIONS
Applicants must be residents of the State of Indiana. Applications must be filed during the periods specified. Once the application is in effect, no other filing is necessary unless there is a change in the status of the property of applicant that would affect the deduction. This application may be filed in person or by mail. If mailed, the mailing must be postmarked before the last day of filing. Any person who willfully makes a false statement of the facts in applying for this deduction is guilty of the crime of perjury and on the conviction thereof will be punished in the manner provided by law. Maximum deduction is $12,480. If filing for a blind deduction, the applicant shall provide the Auditor of the County where the property is located with proof of blindness supported by the records of a County Office of Family and Children, the Division of Family Resources, or the Division of Disability and Rehabilitative Services, or a written statement of a physician who is licensed by this State and skilled in the diseases of the eye. If filing for a disabled persons deduction, the applicant shall provide the Auditor of the County where the property is located with a Federal Social Security Statement of Disability. If applicant is not eligible to receive disability benefits under the Federal Social Security Act, a letter shall be submitted to the Auditor containing a statement from a physician licensed to practice in Indiana that the claimant is unable to engage in any substantial gainful activity by reason of physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than twelve months.