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"� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS -
�' = FOR DEDUCTION FROM ASSESSED VALUATION Cou �own i ear
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! State Fwm 43709 (R6 / SO6)
y� Presvibed by Departmenl of Loml Govemment Firiance
INSTRUCTIONS: ��„File M��
To be Tled in person or by mail with the CountyAudito� of the county where the propeRy is located. 0��a�//
Filing Dates: 1) Real Property: Ounng the 12 months before dune 11 0/ the year the deduction is to be e�+ae!$eN C6_[1Nty �1UOirop
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the year the deduction is to be elfective.
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See ieverse side for additional instruc6ons and qualifications.
Applicant (o er� � contract 6uyei - ee resfrictions on reverse side)
Taxing District Key number / legal description Record number
i /„ /�1 � /" �/-��-�oo•�Ca-�� Pagenumber fO
HCLL.,L-L� � � j- -CIO �JO7cf U
Assessed value of real property as of Mortgage / ConVact indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? � Yes � No
If no, what is his / her exact share of interest? If owned with someone oiher than spouse, indicate with whom.
If name on recorcJ is different than that of applicant, indicate below: Is the property in questlon:
!f � al Property � Mob� Home QC 61.1-7)
N me of mortgagee or contract seller p�'�� � N K
� �" � G� � � D-��,CA
Address of mortgagee or contract sell r(number ana �l � �
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Name o( assignee or other owner or holder of mortgag z� a�
D�' �
Address of assignee (number and s6eet, city, state, ZIF .__e�
Does applicant ovm property in any other If yes, what county? What Tauing DistricY? Has this deduction been requested on
wunty in indiana? property for wnent year? ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20�� 20� 20 20 20 20
Q P �
Signature County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing infortnation is We and corteci and that the applicants was / were
�sident of Indiana and owner of the aforementioned propeRy on March 1, 20
�iature (owne/s f ll name) Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
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