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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
ti. �«� ! State Fwm 43709 (RS / 4-03)
� PrasaiDed Ey Departmeni ot Loral Govemment Finance
INSTRUCTIONS:
To be fled in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1 J Real Property: Dunng the 12 montbs betore May 11 0/ the year the deduction is to be effe�iiie 2 8 ZOQ4
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the year the deduction is to be eHective.
See reverse side for additional instructions and qualifications. /�"1 �
� Gi3SON COUrJ � �• q����
Applicant (owne� co tract buyer- see re trictions on re erse side)
Taxing Dislrict Key number / legal desuiption Record number ,�
�^�'`/`� . 1 /f1d'� (_ oQ � I' N\ Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
o1G-a� �� /QO -000.���- ��/.
If name on record is different than ihat of applicant, indicate below: Is the property in question:
❑ Real Propeity ❑ Moale Home QC 6-1.1-�
�me of mortgagee or contrad seller � /��
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Address of mortgagee or contract seller (number and street, city, sfate, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (number and streef, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
wunty in Indiana? property for current yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 �_ 20 � 20 �� 20 20 20 20
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Signature n County Audilor Date
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I/ We rtify under the penalty of perjury that the above and foregoing information is true and corred and lhal lhe applicants was / were
�si nt of Indiana and owner of the aforementioned property on March 1, 20
� �� ture (owne/s (ull name) Person authorized by duly executed Power of Attomey
� . � _� or by IC 6-1.1-12-.07
F resident address of applicant Address of authorized person
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