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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Strte Fwm 43709 (RS / a-03)
PrescnbeC py Depanment of Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor of the county where the property is /ocated.
Filing Dates: i) Real Property: During the 12 months before May 11 0/ the year the deduction is to 6e effectiNve? �!� 2003
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0/ the year the deduction is lo be effective.
See reverse side for additional instructions and qualifications. � �
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Applicant (ow r or cont t ye�se�strictio►►s o� rGverse si � '
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Taxing District Key number / legal description Record number ��
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, curr�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 wiih whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-7)
�e of mortgagee or contrect seller � � �
Address of mortgagee or contract seller (number nd 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, ciry, sta[e, ZIP code) I !�
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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 amouni of:
20 � 20 � 20 � 20 � 20 �_ 20 20
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Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and cortect and that the applicants was / were
2sident of Indiana an r of t orementioned property on March 1, 20
i ature (owner ull na ) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
F side address of applicant Address of authorized person
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