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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate FOrtn 43709 (R4 / 10-01)
PrescriDetl Dy Departmenl of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: File�}
To be filed in person or by mail with the County Auditor oJ the county where the propeRy is locafed. N � � 1 5 L��2
Filing Dates: 1) Real Property: During the 12 months belore May 11 of the year the deduction is to 6e effective.
2) Mobile Homes assessed under IC 6-1.1-7: Be(ween January 15 and March 31 0/ th� ear the de uct/ �s to e ctive.
See reverse side for additional inst�uctions and qualifica6ons. /�J y' c
" G.9SQN COU��T. Y :UDiTr„
Applicant (o r o ct buyer - ee rest�ons qh verse side)
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Taxin District Key number / legal description Record number O�
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equilable
March 1, current year March 1, t year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone ofher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real P�operty ❑ Mobile Home (IC 61.1-n
me of moAgagee or conVad seller
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Address of mortgagee or conVad seller (number an street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and stieet, city, state, ZIP code)
Does appliqnt own property in any other If yes, what couniy? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for curtent yea(? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
zo 20 � zo 0 5 20 �� zo 20 �� zo Q`L
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Signature County Audftor Date
' We certify under the penalty of peryury lhat the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
i ture (owners full name) Person authorized by duly executed Power of Attomey
� � � or by IC 6-1.1-12-.07
Ful' �sident address af applipnt Address of authorized person
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