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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03)
PrescnGed by Deparlment of Locai Govemment Finance
�RUCTIONS:
� oe filed in person or by mail with the Counry Auditor of the county whe2 the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to be effective. � j ���3
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side for additional inshuctions and qualifications. � �%
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Applicant (owner or co ct u r see reshictions n vers si
Taxing District Key number / legal description Record number p,�
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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, curtent year March 1, c�ent 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 the property in question:
❑ Real Property ❑ Mobile Home QC E1.1-7)
Name of mortgagee or contract seller
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�'ress of mortgagee or contred seller (number and st et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state_.Zle�.v+��- - - —
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Does applicant own property in any other If ye ias this deduction been requested on
county in Indiana? ), i �/ � �roperty for current year? ❑ Yes❑ No
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Deduction approved in the amount of
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Signature Counly Auditor Date
I I We certify under the penalty of perjury that the above and foregoing infortnation is true and cortect and that the applicants was I were
a resident of Indiana and owner of the aforementioned property on March 1, 20
�nature (owners full nam ) Person authorized by duly executed Power of Attomey
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Full esident address of applican Address of authorized person
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