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i i�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
's'�; FOR DEDUCTION FROM ASSESSED VALUATION W � Year
� • State Fom.� 43709 (R6 / SO6) � �
� Presoibetl by Depariment of Local Gwemment Finarice
AUG 1 7 2001
INSTRUCTIONS: File Maric
To be /iled in pe�son or by mail with lhe County Auditor o/ the county whe�e the property is located. a�
Filing Dates: i) Real Property: Dunng the 12 months before ,lune Il of the year the deduction is, ,tQ be elfectjye��
2) Mobile Homes assessed under IC �6-1.1-7: Between January 15 and March 2 oft}1��� fh@���Yck4JDl��Abe eflective.
See �everse side for additional instruclions and qualifications.
contract
Taxing
Assecsed value of real
March 1, curcent year
16 no, what is his / her exad
ar� �e�e�ncnons on reverse
f( / ,. ° !n/
Key number / I�gal description Record number �
(0����J�� ��'/OI� .
� �a Page number ��/
D
as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the ole legal or equitable
March 1, curren year owneR" ❑ Yes' ❑ No ' '
e of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of
of mortgagee or contrad seiier
�
below:
Address of mortgagee or contract seller (num�er d street, city, state, Z!P
Name of assignee or other awner or holder of mortgage
Address of assignee (num6er and st2et, city, sfate, ZIP code)
Does applicant own property in any olher I If yes, what county? Whal i
counry in Indiana?
Dedudion approved in the amount of:
20 �e 20 �� 20
� P
Signature
COUNTY AUDITOR
�
County Auditor
20
Is lhe property in question:
❑ Real Property ❑ Mobiie Home pC 61.1-�
e
Dra��'er NO.�(�lQ�� ����4
CardNO . .....................
:scea on
. , - , -. __....... ,,,�� : u i es� No
�
Date
20
�' We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of lhe aforementioned properfy on March 1, 20
� Si nalure (owners full na ) Person authorized by duty executed Power of Attomey
.,.� rn��_ , o� bY ic s-�.i-�2-.0�
Full
� 43S/
of authorized person