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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
/ �+ �M� J Stare Pwm 43709 (RS / 4-03) -
� Presaibed by Departmen; of local Gtivemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property� Dunng the 12 months before May 11 of the year the deduction is to be elfectiv� E C 2 1 2005
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 oI the year lhe deduction is to be eHective.
See reverse side for additional instructions and quali�cations. �j,�� ��
01880N C611NfiV Al1Blfi6[i
Applicant (owpQror,contrac(
�.��! �-�i�
Assessed value of real property as of
March 1, current year
�io, what is his / her exact share of interesl?
on revers,� side)
Key number / legal description Rewrd number �
D/Q ' fj � �%� —� Page number � �� �
i v �
MoAgage / ContraIX indebtedness unpaid as of Is the appliwnt the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
If name on record is different ihan that of applicant, indicate bel��w:
,3me of moAgagee or contrad seiler ,,
owned with someone olher than spouse, indicate with whom.
Address of mortgagee or contred selier (number and street, city, state,
Name of assignee or olher owner nr holder of mortgage
(number and street: city; slate, Z!P
Does applicant ovm nrcperty in any oth�r I I( •�; t°hat county? bVhat Taxin
county ir, Indiana? � �
I
COUNTY AUDITOR
_ -- -- -- — -
Deduction approved in Ihe amo�mt nt:
zo
Signature
I 2n�_-- -
�---- � ----
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1
�d on
Drawer NO. o,�,—„ 7%a,S °� No
�rd NO . ...... .............
zo_o9- zo ------ zo zo
1 —� --- �
__ Counfy Auditor Dat
Zo
We cetiihj unAer IhP ,.�;�alty of peqn�� �h�t tne above and forcpoina info:maf�n is tm? and corred and that the applicants was / were
resi�ent of Indfana ar•d owner o( tha afnrementioned propeRy on March 1, 20 __
t�r.
Person aurhnrizerl by duly exewted Power of Httomey
or bv IG 6-1.1-12-.07
ruil Pesident aart�ess of aoolicant � IAddress of authonzed person