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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
��� J Stata Fortn 43709 (RS / 4-03)
� Prascn�ed by Department of Local Gtivemment Financa
INSTRUCTIONS: ��T '�F li e Mar1c
To be filed in person or by mail with the County Auditor o! the county where the property is located �i �i ���
Filing Dates: 1J Rea/ Property: Dunng the 12 months belore May 11 oJ the year the deduction is,to be-eHective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MarcA 2 of the year the dedJUW'g9 jFs to be eHective.
See 2verse side for additional instructions and qual�cations.
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Applicant(ownerorcontract - restnc6onso rever e)�D Ggs�;�CpUpli� r.'��i1e`• •
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Taxing Dislrid Key number / legal desuiption Record number Jl�
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Assessed value of real prope as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent 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 diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Horrie (IC Cr1.1-�
�ame of moRgagee or contrad seller �� �
Address of mortgagee or contract seller (number and street, city, state, ZI
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st�eet, city, state, ZIP code) -
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current yea(? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 �� 20 20 20 _� 20 0 20 20
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Signalure County Auditor Date
1/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resideni of Indiana and owner of the aforementioned property on March 1, 20
Sjg�alure ners (ull name) Person aulhorized by duty executed Power of Attomey
t�� or by IC 6-1.1-12-.07
F sident address of applican Address of authorized person
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