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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS I 4-03)
PrascriEed by Department of Local Govemment Finance
INSTRUCTIONS:
To be �led in person or by mail with the CountyAuditor of the county where the property is located. FEB 1 3 2�D�f
Filing Dates: i) Real Property: During fhe 12 months before May 11 of the year the deduction is to 6e eflecfive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of ine year the deduyction is to��be ef(ecfive.
See reverse side for additional instructions and qualifications. i�t ;r,!� -.1! �;/
� ' GIBSO�ICCU�lTt �uuROR ;
Applicant (ow rcontract buyer- �re t'ctions on �everse side},
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Taxing Disirid Key number / legal description Record number
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Assess value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant t e sole legal or equitable
March 1, curcent year March 1, currenl year owner? ❑ Yes 0 No
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If no, what is his / her exad share of interest? If owned wilh someone other than spouse, indicate with whom.
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If name on record is different lhan that of appliwnt, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
��me of mortgagee or wntrad seller �
Address of mortgagee or wntrad selier (num er and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZIP code)
Does appliwnt own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year?0 Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount ot:
20 20 � 20 � 20 � 20 �_ 20 20
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Signature County Aud'Ror Date
�/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applirants was / were
�resident of Indiana and owner of the aforementioned property on March 1, 20
Si atur ers /ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F re ' nt address of appliqnt Address of authorized person
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