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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� �w ! State Form 43709 (RS / 4-03) � • • -�
Presaibed by DepaMient o( Local Govemment finarrce i�i � '
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INSTRUCTIONS: FEB ��'�'���
To 6e filed in person or 6y mail with the Counry Auditor ot the county where the property is located.
Filing Dates: 1J Real Property.� Dunng the 12 months be%re May 11 0l the }rear the deduction is to be�ellective. � �. �i �,
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the ye,Caur �th�e deduction;is�to be e8ective.
See reverse side /or additional instrucfions and qualifications. /:' g�ggON COUN' `'��`-�� ��'�
Applicant l�vnerorcontract buyer- see 'ctions on reverse side) � �
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Taxing Distrid Key number / legal description Record numberO !��
DLZJ���q ,,,, � � O/ ) — O / �O Page number
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Assessed vatue of real property as o Mortgage / ContraIX indebtedness unpaid as of Is the applica tr� e sole legal or equitable
March 1, curtent year March t�en�ear 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 than that of applicanl, indicate below: Is lhe prope in question:
❑ R�ty ❑ Mobile Home QC 61.1-�
�me of mortgagee or contrect seller
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Address of mortgagee or contract seller (number and 2et, ci , tate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st�eet, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? properry for current yeaf?0 Yes❑ No
_ � COUNTY AUDITOR
Deduction approved in lhe amount of:
20 _.f 20 0 6 20 �� 20 _� 20 20 20
P e
Signature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Sig e ners full name) Person authorized by duly executed Power of Attomey
� � or by IC 6-1.1-12-.07
Full id n address of applicant Address of authorized person
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