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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION �� �`� ear
�. «. / State Fwm 43709 (R5l 4-03) .
� Prnscri�ed by Department of Local Govemment Finance
INSTRUCTIONS: �-y,�ile M�c�
To be filed in person or 6y mail with the Counry Auditor of the county whe2 the property is located. O��R'� '"�'��
Filing Dates: 1J Real Property: During fhe 12 months be%re May 11 0/ the year the deduction is to be e� COUNTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�cA 2 0( the year the deductron is to be effective.
See reverse side for additional instructions and quali�cations.
Applicanl (o ner or contract buyer- s 2sMdions on reverse �de)
Taxing District Key number gal description Record number 0�
W� [iQ ( 1°I � ��p — % �6a � � Page number `� �
/ ,L \LJ �
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as �f Is the applicant the sole legal or equitable
March 1, current year March 1, current year � � �� 5"OO ,� owner? ❑ Yes ❑ No
/��; d�d -
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 lhat of appliwnt, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hmie (IC fr1.1-�
�me of mortgagee or contrad seller n /
�• G�7-Q' Q,
Address of mortgagee or contraIX seller (number and re f, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, sfate, 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? properiy for current year?�] Yes❑ No
COUNTY AUDITOR � —
Deduction approved in the amount of: ' ���D
20 / zo zo� Dra�ver NO..s/•' .... —
zo
� ..:..
� Card NO . ................
Signature Coun
� We certiy under the penalty of perjury lhal 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
Signat e(owners full name) person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resid nt a dress of applicant Address of authorized person
.y
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