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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun�f Townshi�p7 _ Year
+ �H� ! SUte Form 43709 (R5/4-03) �,� � �"� `,J �}
� PmscnEed by Department of Local Govemment Finance r� (�
�1_1 gJ
JUN 2 2 2004
INSTRUCTIONS: File Mark
To be filed in person or by mail with the CountyAUditor of the county where the property is located. //� �%
Filing Dates: f) Real Property: During the 12 months before May 11 0( the year the deduction is to 6e eBectLe.�J��–j�c��cy
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the�deduciion:isYO be'effective. �
See reverse side for additional instructions and quali�cations.
�lo" 13 -35 _.300 -
Applicant (owner
Taxing
see re'strictions n rev e side)
J(�./d� �
Key number / leg
Assessed value of real property as of
March 1, wrrent year
ii no, what is his / her exact share of interest?
If name on record is different than ihat of
of mortgagee or contract selier
Ob3-Dt
Mortgage / Contrad ii
March 1, current ye�r
� V il
indicate below:
�l
Record number Q
� � _O T Page number � �j � Q
(.J J l
iness unpaid as of I Is the applicant e sole legal or equitable
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contract seller (number and street, city, state. ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city. �tate, ZIP code)
Does applicant own property in any other I If yes, what county^ i 4Vhat Taxing District?
wunty in Indiana? I
� — � COUN i Y AUDITOR
20
Signature
approved in the amount of:
20
Is the property in question:
❑ Reai Properry ❑ Mobiie Home pC 61.1-
Has this deduction been requested on
property for current yea� � Yes ❑ No
20 � 20 _Q� 20 �_ 20
�° �__ P P
County Auditor Dat
20
/ We q�rtify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resj��enl of Indiana and owner of the aforememioned property on March 1, 20
full name)
.LOL- /�
;� ot applicant
Person authorized by duly execuled Power of Attorney
or by IC 6-1J-12-.07
authorized person