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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
- � FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� State Form 43709 (Rd / 10-07)
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� Prperibed by Department of Lacal Govemment Finance �
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor oI the county whe2 the property is loca�.� 2� 2��2
Filing Dates: 1) Real Property: During the 12 months 6e%2 May 11 0/ the yea� the deduction is to be effec 've.
2) Mo6ile Homes assessed under IC 61.1-7: Belween January 15 and Ma 31 0/ the y a� dedu on y to be elfective.
See reverse side foradditional instmctions and qualifica6ons. ��Bv�y �u� �Nrv � UDiTOF
Applicant (owner or contract 6uyer- see restn ons on rever side)
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Taxing Dislrid Key number / legal description Record number
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O/ - a o 3 � Page number
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, curtent year ownef? ❑ Yes ❑ No
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If no, what is his / her exad 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 Properly ❑ Mobile Home QC G1.1-�
/�me of mortgagee or contrad seller ^
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Address of mortgagee or conVad seller (number and street, city tate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent yean � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 0 20 20 �� 20 �� 20 �� 20 �
T�4-baA- � P �
Signature County Auditor Date
/ We ceM1ify under lhe penalty of perjury ihat the above and foregoing infortnation is true and corred and lhal the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
S' ure (owPe s Iull r�am . Person authorized by duly executed Power of Attomey
-Y or by IC 6-1.1-12-.07
ull resident address of applipnt Address of authorized person
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