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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun To�
` J Stale FoRn 43709 (R4 / 10-07)
�u.
� Prescribed by Department of Loral Govemmeni Finance
INSTRUCTIONS: � l�{6i1�
To 6e filed in person or by mail with the County Auditor o/ the county whe2 the property is fo ted�
Filing Dafes: 1) Real Property: During fhe 12 months before May 11 0/ the year the deduction �s to be e�(iv�. 2��3
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of th�r trie deductic
See reverse side loradditional inshuctions and qualifrcations. „ / i�j
or
Taxing Distrid
l/`� "" / 'Ul �
Assessed value of real
March 1, curtent year
buyer-see
(�6ns on reverse sid� /% Gl�"'• �
� y;:��, �� � �� �`�.' "' ' —' /
Key nu ber / legal description Record number
�
Year
to be effective.
� , / �� Z_ 00 �9/� 0� Page number Y/
v � O ��
irope as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal i
I( no, what is his / her exad share of interest?
If name on record is
mortgagee or contrad
Address of mortgagee or
March 1, cunent year owneR ❑ Yes ❑ No
� � _ aa.79/ ��
If owned with someone other than spouse, indicate with whom.
that of applicant, indicate below:
city, stafe, ZIP
Name oi assignee or other owner or holder of mortgage
Address of assignee (number and sheet, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid?
counry in Indiana?
� J% COUNTY AUDITOR
Deduction approved in e amounf of:
zo
Signature
zo
20 � 2o U I zo �
County Auditor
s the property
❑ Real Property ❑ Mobile Home QC E1.1-�
Has lhis dedudion been requested on
property for current yeaf? � YesO No
20 �� 20
P
Date
/ We certify under ihe penaity of perjury that the above and foregoing informalion is true and correct and lhat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
g�` ture (owners full name • Person authorized by duly executed Power of Attomey
�l",,/�l,,,,,. nr, 1, 1. , a.� o�by�cs_,.,_,z_.o�
resident address o7applipnt Address of authorized person
I,�o,L � S�-� h n,.5,�� 1 N�?l�