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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03)
PresaiDeA by Department of Local Gtivemment Finance
Coun Township Year
INSTRUCTIONS: 2 ���
To 6e filed in person or 6y mail with the CountyAuditor of the county where the property is located. �p,N
Filing Dates: 1J Real Property: During the 12 months be7ore May 11 01 the year the deduction is fo be el%ctive.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year�b�le o be e/%ctive.
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See reverse side /or additional instructions and qualifications. 0 �� A D�
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Applicant (ow ntracf 6uyer - se estriction verse side) ,
Taxing Disirid Key number / legal description Recor n ber O
Q O 1' _ Q �'y� Page number �
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Asse d value of real property as of MoAgage / Contra in ebtedness unpaid as of Is the applicant the sole legal or equitable
March t, curtent year - March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the property in question:
❑ Real Pmperty ❑ Mobile Home QC Et.1-�
me of moAgagee or contraIX seller �^
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Address of morigagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand stieet, city, state, ZIP code)
Does appliwnt own property in any other If yes, what county? What Taxing District? Has this deduction been requesled on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in lhe amouni of:
20 /) . 20 � 20 �� 20 �� 20 20 20
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Signature County Auditor Date
' We ceAify under the penalty of perjury thal the above and toregoing information is true and corred and that ihe applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull ame) Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
Full r i nt res applicanl d ess of authorized person
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