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                 APPLICATION FOR BLIND OR DISABLED PERSON’S                                                     COUNTY                  TOWNSHIP       YEAR 
                 DEDUCTION FROM ASSESSED VALUATION 
                 State Form 43710 (R14 / 9-24)                                                                                                         
                 Prescribed by the Department of Local Government Finance 
 
 Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9. 
  
 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) 

 Is applicant the sole legal or equitable owner?   If No, what is his/her exact share or 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                        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)? 
                                                   ☐ 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                ☐ No                                                               ☐ 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                                                                                 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 and provide proof of blindness or disability, as applicable. 
    
 • 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 or 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 may be guilty of the 
   crime of perjury. 
    
 • Maximum deduction is $12,480. 
    
 • The applicant’s taxable gross income in the preceding calendar year cannot have exceeded $17,000. 
    
 • As proof of blindness, the applicant may 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 diseases of the eye. (IC 6-1.1-12-12(b)) 
    
 • As proof of disability, the applicant may provide the auditor of the county where the property is located with a 
   Federal Social Security Statement of Disability. An individual with a disability not covered under the Federal 
   Social Security Act shall be examined by a physician and the individual’s status as an individual with a disability 
   determined by using the same standards as used by the Social Security Administration. (IC 6-1.1-12-11(e),(f)) 
    
 • For purposes of this deduction, “blind” has the same meaning as the  definition under IC 12-7-2-21(1) and 
   “individual with a disability” means a person unable to engage in any substantial gainful activity by reason of a 
   medically determinable physical or mental impairment that can be expected to result in death or that has lasted 
   or can be expected to last for a continuous period of not less than twelve (12) months. (IC 6-1.1-12-11(c),(d))