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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Tawnship Year
l�w J State Fortn 43709 (R5 / 4-03)
PrescriDed by Depanment ot Local Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is Ixate�� � ��
Fi/ing Oates: 1J Real Property: During fhe 12 months belore May 11 0/ the year the deduction is t e e t'
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea e�ed�c t Hective.
See reverse side Por additional instructions and qualifications.
0 C T 15 2003
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Applicant (owner or confrac 6 ye� - see resMctions on reverseside)
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Taxing'�istn� � Key number / legal description e r um er
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applirant the so e legal or equitable
March 1, current year March 1, current year owner? s❑ No
7, t� c�0
If no, what is his / her exacl share of interest? " If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the pr perty in question:
eal Property ❑ Mobile Home QC E1.1-7)
•ie of mortgagee or contracl seller
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Address of mortgagee or contrect seller (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 (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
zo zo_Q,� zo p(, zo o� zo 03 20 09 zo
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Signature County Auditor Date
•' We certiTy under the penalty of perjury that the above and foregoing information is true and cortect and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owner's (ull name) Person authorized by duly executed Power of Attomey
��J or by IC 6-1.1-12-.07
Full resident addre of applicant Address of authorized person