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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Form 43709 (RS / 4-03)
PrascnDed by Departmeni o( Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with fhe County Auditor of the county where the property is located. �,� �� 2004
Filing Dates: 1) Real Property: Dunng the 12 months be(ore May 11 0/ the year the deduction is to be�eBective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0(� year the deduction is to be effective.
See 2verse side for additional instructions and quali�cations. / � U' ��l
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.-�ac, •� r.C�'1:;Y AU�iT . .
Applicant (owner or ntr t buyer - see restncti on revers si e)
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Taxing D/i�try�d Key number / legal description Record number
\����L oe%6/w )(_, ✓����3(CS��C7 Pagenumber
Assessed value oi real property as of MoAgage / ContraIX indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year March 1, � year owne(? ❑ Yes ❑ No
O O v V
If no, what is his / her exact share of interest? owned with someone other lhan spouse, indicate with whom.
If name on record is different than lhat ot applicant, indicate betow: Is the property in question:
� Real Property ❑ Mo6ile Home QC fr1.1-�
^�'�me of mortgagee or conlrad seiier
Address of mortgagee or contraG seller (number and street, city, st 1
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year?0 Yes� No
COUNTY AUDITOR
Deduction approved in lhe amount of:
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Signature County Auditor Date
/ We certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applirants was / were
sident of Indiana and owner of the aforemenlioned property on March 1, 20
5i ature (owners full nam Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
F II re dent address of licant Address of authorized person
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