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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION s Year
�T �« / State Fwm 43709 (RS / 4-03) ,
� Prescribed by DeOanment of local Gtivemment Finance
INSTRUCTIONS: F��
To be filed in person or 6y mail with the County Auditor o) the county where the property is located. ���
Filing Dates: fJ Real Property: During the 12 months belore May 17 0/ the year the deduction is to 6e @���OUNTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the y��the deduction is to be eNective.
See reverse side lor additional instiuctions and qualiTcations.
Applicant (ownero contract buyer- see tions on reverse side)
�
Tauing Distrid Key number / legal description Recor number �
G��3� � I—a I OO �- �»� Page number !"�' �
`'CJ ��
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, nt year owneR � Yes ❑ No
�a �c�
If �io, what is his / her exact share of interesl? If owned with someone other lhan spouse, indicate with whom.
�L-�G -a3-aoo- aoi �oS-�oi
If name on record is dif(erent ihan that of applicanl, indicate below: Is e pro erty in question:
roperty ❑ Mobile Home (IC 61.1-�
�me of moRgagee or conlrad seller
Address of mortgagee or contract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of moAgage
�
Address of assignee (number and street, city, state, ZIP code) i
Does applicant own property in any other If ves. what county? What Taxing Distrid? Has lhis deduclion been requested on
county in Indiana? property for wrrent yea(? 0 Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 �� 20 20 20 20 20
� P
Signature County Auditor Date
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'� We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicants was / were
esident of I iana and owner of the aforementioned property on March 1, 20
3ignatur wners full e) Person authorized by duty executed Power of Attomey
- or by IC 6-1.1-12-.07
Full resi enl a dress of aDPlicant Address of authorized person