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APPLICATION FOR BLIND OR DISABLED PERSON'S DEDUCTION FROM ASSESSED VALUATION State Form 43710 (R11 / 11-15) Prescribed by the Department of Local Government Finance COUNTY TOWNSHIP YEAR 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: 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. See reverse side for additional instructions and qualifications. Name of applicant (owner or contract buyer) Is applicant the sole legal or equitable owner? If name on record is different than that of applicant, indicate below: Yes No If No, what is his/her exact share of interest? If owned with someone other than spouse, indicate with whom: Name of contract seller Address of contract seller (number and street, city, state, and ZIP code) 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 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 Name of contract seller Taxing district Key number / legal description Signature of County Auditor Date filed (month, day, year) Date signed (month, day, year) Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. Is the property in question: Real Property Annually Assessed Mobile Home (IC 6-1.1-7) Reset Form ---PAGE BREAK--- 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. The applicant’s taxable gross income in the preceding calendar year cannot have exceeded $17,000. 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 the Division of Family Resources or the Division of Disability and Rehabilitative Services, or a written statement of a licensed optometrist or 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. The applicant must be examined by the physician and his or her disability status determined by using the same standards as used by the Social Security Administration.