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�" STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' : FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
S J Sfate Fortn 43709 (R4 / 10-07)
PrescribeE by Department of Loral Govemmeni Finance
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INSTRUCTIONS: AUG 2 1 20�j�e Mark
To be filed in person or by mail with the County Auditor of the counly whe2 the property is located+ �
Filing Dates: 1) Real Property: During the 12 months betore May 11 of the year the deduction 's fo 6e effecfive
2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March of the ear he ductio is be ef(ective.
See reverse side for additinnal instmr.linns and nualificafrnnc . J
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Ap � t(owner or contracf yer - see fnctions on reverse ide)
Taxing Distrid Key nu r/legal description Record number Q�
/ a y oO� � D/ 1 r''� Pagenumber O
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Assessed value of real property 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
O Vvv
If no, what is his / her exaci share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan ihat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
��ne of mortgagee or contrad seller
5
Address of mortgagee or contracl seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand st�eet, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Disiric4? Has this deduction been requested on
county in Indiana? property for current yeaf?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 Q� 20 Q� 20 20 � 20 �'Z 20 �_ 20 �_
0 � i - � P
Signature County Auditor Date
We certiy under ihe penalty of perjury that the above and foregoing information is true and corred and that the ap�licants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Si ature (owner full name) Person authorized by duly exewted Power of Attomey
. or by IC 6-1.1-12-.07
F II resident add s of appl cant Address of authorized person
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