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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� «. �� Siate Form 43709 (R4l 10-Ot) � �
� PrescribeA by Department ot local Govemment Finance
INSTRUCTIONS: F E B �Fi e M 003
To be filed in person or 6y mail with the County Auditor of the counfy where the property is located.
Filing Dates: 1) Real Property: During the 12 months be)ore May 11 of the year the deduction is to ct� .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 0/ th�4� AY,�.A�Hecfive .
See �everse side /or additional instiuctions and quali�cations.
Applicanl (ownerorcon ract 6�yer- see rest ti s on 2ve side)
Taxing Dislrid Key number / legal description Record number O�
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Assessed value of real properiy as of Mortgage / Contrad indeb)edness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year �J,r Q � � owner? ❑ Yes ❑ No
t 1
Q� �
If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real RopeAy ❑ Mobile Hort�e QC 61.1-�
"ame of moRgagee or contract seller
-� 0 1'��
Address of mortgagee or conlract seller (number and st , city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sUeet, city, s[ate, ZIP code)
Does applicanl own property in any olher If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current yea(? � Yes 0 No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 �_ 20 �� 20 0 5 20 �C� 20 20 �e 20 ��
o � -� P
Signature County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
� resident of Indiana and owner of the aforemenlioned property on March 1, 20
igna re (owners full na e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F II resident address appli nt � Address of aulhorized person
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