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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION C n To sh Year
1 p� / State Fartn 43709 (RS / 4-03)
� PrescriDed Gy Department of Local Govemment Finance
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INSTRUCTIONS: F e '
To 6e filed in person or 6y mail with the County Auditor o! the county where the property is located.
Filing Dates: lJ Real Property: During the 12 months be%re May 11 o/the year the deduction is to e��p�y.� OU Y AUDITOR
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0) the year the deduction is to be effective.
See reverse side Ior additional inst�uctions and qualifications.
Applicant (o or contrac buye - ee restrictio on reverse side)
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Taxing Dislrid y number / legal description , Record number �//
\.�/.luKS'/ny uCx ' ���- Q6.L/ 0�—W Page number r
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the appliqnt ihe sole legal or equitable
March 1, wrrent year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? Ii 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:
O Reat Property ❑ Mobile Home QC 61.1-�
�e of mortgagee or contract seller �/�
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Address of mortgagee or contrad seller (� ber and st2et, city, stat "D
Name of assignee or other owner or holder of mortgage Dr ` -
a �'er N ,
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Address of assignee (numberand street, city, state, ZIP code) Card N �� �'�.z'�•�
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Does applicant own property in any other If yes, what county? iction been requested on
county in Indiana? ' ;,urrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 � 20 � 20 �� 20 0 9 20 20 20
P +°
Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Signatu�e (owners Iull name) Person authorized by duty executed Power of Attorney
m� or by IC 6-1.1-12-.07
Full re ident addres of applicant Address of authorized person
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