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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Fofm 43709 (R4 / 70.01)
Prescribe0 by Department of Local Govemment Finance
Count Township Year
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INSTRUCTIONS: �, � � � � �` �i�'JZtark
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 months belore May 11 olthe year the deduction•is�to.be eNectiv� /I �
2) Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 91�of tfie year�the dedGction�r,"�s-to�be eHective.
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See reverse side for additional instructions and quali�cations_
Ap licant (owner or confract buyer- see restrictions on reverse side)
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Taxing Dislri Key number / 7�egal des ti n Record number
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Assessed value of real property as of MoAgage / ContraG indebtedness unpaid as of is the applicant 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.
If name on record is different lhan that of applicant, indicate below: Is lhe property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�e of mortgagee or contract seller � .
Address of mortgagee or contrad selier (number and street, city, state, ZIP
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Name of assignee or other owner or holder of mortgage /
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Address of assignee (numberand street, city, slate, ZIP code)
Does applicant own property in any other If yes, what wunty? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent yeaR� Yes� No
COUNTY AUDITOR
Deduction approved in the amount of: h
1 �.li
20 20 � 20 � 20 20 20 Q~J 20 �
s D � p P
Sig ture County Auditor Date
Ne certify under the penaity of perjury that the above and foregoing information is true and correcl and that the applicants was / were
�ident of Indiana and owner of the aforementioned property on March 1, 20
'gn ure (owners (u name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F I sident ad ess of applicant Address of authorized person