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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03) �
Prasc�nEetl by Departrtrent of Local Govemment Financa
INSTRUC710NS:
To 6e filed in person or 6y mail wfth the Counry Auditor of the county where the property is located. ,/
Filing Dates: 1) Real Property: During the 12 montbs be%re May 11 of tbe year the deduction is to be eRee�t��e.,,,� ,Q�°�
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the �ducti�n �b�b@�lfective.
See reverse side for additional instructions and qualifications. G18SON GO�N `
Applicant (ovmer or contract buyer - ee restrictions on reverse side
�
Tauing Distrid Key number / legal description Rewrd number Q
� ��� Page number I �
Assessed value of real property as of Mortgage / Contrad indebtedness unPaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year � O) a� � owneR ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned wilh someone other lhan spouse, indicate with whom.
�- .� ,/�a. �o. ��.�-��
If name on record is different than that of applicant, indicate below: Is lhe property in question:
- ❑ Real Property . O Mobile Home QC 61.1-�
�me of moitgagee or contrad seller
� ` a � � k � Q Ca�C�
Address of mortgagee or contract selier (number and street, city, state IP �
o -a� I
Name of assignee or other owner or holder of mortgage
.Address of assignee (number and st2et, city, state, ZIP code) �
Dces applicant own property in any other If yes, what county? Whai Taxing Distrid? Has this dedudion been requested on
county in Indiana? .- property for wrrent year? � Yes 0 No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �0 �_ 20 0� 20 20 20 20
P P I ��
Signature County Auditor Date
.� We certi under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resid of Indiana and owner of the aforementioned property.on March 1, 20
i ure (owners full name) Person authorized by duty executed Power of Attorney
� or by IC 6-1.1-12-.07
Fuil sident address applicant Address of authorized person