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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R6 / 5-06)
Presaibed by �epartment of Local Govemment Finance
INSTRUCTIONS:
To be liled in person or by mail with lhe CountyAudrtor.of the county whe�e the p�opeRy is ���,
Frling Dates: 1) Real Property: During the 12 months before �une 11 of the yea� the deduction is to 6���ec�v�..
2) Mobile Homes assessed unde�lC 6-1.7-7: Between January 15 and March 2 o(the year the dedyF�yon is to be effective.
See �everse side fo� additional instructions and qualifications. �o•n�a� '`sh U ��TpR
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Appticant (owner r tract b�{yer - s�eYesfrictio� se ide , Q �
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Taxing Distrid Key number / legal escription Record number�L _�
\ O�C�t/yK.�jLt� a/c- � ti _� -1- 3� - ct�p .! S°J '°d �o Fage number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, curcent year March 1, current year owneR ❑ Yes ❑ No
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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 lhe property in question:
�Real Property ❑ Mobile Home pC &1.1-�
me of mortgagee or contrad seller .
Address of mortgagee or contract seller (number and 2et, city, state, ZIP �
Name of assignee or other owner or holder of mortgage " �
Address of assignee (num6er and sGeet, city, state, ZIP code) -.
Dces applicant own propeAy in any other If yes, what counry? What Taxing Distrid? Has this deduqion been requesled on
county in Indiana? property for cunent year? rl Yes � No
/%—oZ -� d 3 8' COUNTY AUDITOR
Dedudion approved in the amouni of:
20�_ 20 � 20 20 20 20 20
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Signature County Auditor Date
'� We certify under lhe penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signa e(owners lull nam � Person authorized by duly executed Power of Attomey
' � , L�LC(_ � .xyLi � , or by IC 6-1.1-12-.07
Full resident address ot applicanl Address of authorized person
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