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                 APPLICATION FOR BLIND OR DISABLED PERSON'S                                                         COUNTY                  TOWNSHIP                   YEAR
                 DEDUCTION FROM ASSESSED VALUATION
                 State Form 43710 (R13 / 1-20)
                 Prescribed by the Department of Local Government Finance
                                                                                                                                            File Mark
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 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.
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           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 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. 

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 the diseases of the eye.

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.

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.