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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
: �� �✓ State Form 43709 (R5 / 4-03)
Prescnbetl by Depanment ot Local Govemment Finance
�
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where fhe property is located. Q� � Q Z 2004
Filing Dates: 1) Real Property: During the 72 months be%2 May 11 0/ the year the deduction is to be effecfive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 0! the year the d�edu�ction�is to be e(fective.
See �everse side for additional instructions and qualifications. �—`✓'t.�.-� �--(1'%
G:SSO:d �uU;.; v t,UD(TC3 1
(owner or contract
Taxing Distrid
see restrictions on reverse
Assessed value of real properry as of
March 1, current year
If no, what is his / her exact share of interest?
Key number / legal description Record number
ao�'�'
O/Q_ O ���,� Pagenumber J,�/ /
7 ��% �O
MoAgage / Contracl indebtedn ss unpaid as of Is the applicant th ole legal or equitable
March 1, current year owneR Yes ❑ No
i�SDoa a� y��_ � u
If name on record is different than that of appiicant,
If 6wned with someone other than spouse, indicate with whom.
below:
PropeAy O Mobile Home (IC 61.1-�
of moAgagee or contrad
Address of mortgagee or conlracl seller
street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
- - - -
--
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Address of assignee (number and street, city, sfate, ZIP code) �� � L l �� �
�
................. �i� p���
Does applipnt own property in any other If yes, what wunty? What' ���j`y ted on
county in Indiana? ; ❑ No
............ .. ..Oi�? .IaA�E.IQ
,�/�/� h�� h�-, -�
/A /0 M n n„ �I _ � COUNTY AUDITOR
Deduction approved in fhe amount of:
2�
SignaWre
zo � I Za � I zo P zo
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Counry Auditor
20
Date
20
We certify under the penalty of perjury that the above and (oregoing intormation is true and corred and that the applicanls was / were
��sident of Indiana and owner of the aforementioned property on March t, 20
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person
.� 76 �O