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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION � Coun Township Year
��w� I State Fortn 43709 (RS / 4-03)
Ptescnbetl py Department of Loral Govemment Finance
INSTRUCTIONS: T +'�File Mark
To be filed in person or 6y mail with the County Auditor of the county where the p�operty is lo�. ��`d '� Fyyj
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 0l the year the deduction is to be eHective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0! the yU?! ih�d v�uon is to be eNective.
See reverse side for additional instructions and quali�cafions.
Applicant
Taxing
��+�/'V�(�-C �
Assessed value of real property
March 1, current year
reverse side)
Key number / legal descri�
c�G n/a-/s-o?ao-o
V �� - ��
Mortgage ! ContraG indeE
March 1, wrrent year
If no, what is his / her exac[ share of interest?
If name on record is different than lhat of applicant, indicate
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AUD;TOR
�/� � Record number
n � oo�
�y � Page number
/
�dness unpaid as of Is the applicant the sole legal or equitable
`� �' �O� ! ownef? ❑ Yes � No
d
Ii owned with someone other than spouse, indicate with whom.
.me of moAgagee or contreIX seller �/�
Address of mortgagee or conirad seller (number and reet, city, state, ZIP
Name of assignee or olher owner or holder oi mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other I If yes, what county? What Taxing District?
county in Indiana?
COUNTY AUDITOR
Deductic Dra��'er \`��Q�•��.�.�.Y?'
�
Zo O
�
Signature
CardNO . .....................
zo � 20
County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
Has this deduction been requested on
property for current yea(? � Yes ❑ No
zo
Date
Zo
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March t, 20
name)
tldress of applicant
(L-, L �3� r
Person authorized by duly executed Power of Attorney
�� Q� or by IC 6-1.1-12-.07
L�i �'r r
Address of authorized person