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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S�ale FoRn 43709 (R4 / 10.07 )
Prescribed by Depariment of Local Govemment Finance
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Coun Township Year
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INSTRUCTIONS: Fite Mark
To 6e filed in person or 6y mail with the County Auditor o/ the county where the property is located. �UN g Z003
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 0/ the ��ar the deduction7is[� to be eflec 've.
See reverse side loraddifional ins6uctions and qualifications. ��ai��7Y�-�-
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Applicant (o r r contracf buyer - see trictions on rev side) ' ..
Taxing Distrid Key number / legal descriplion Record number ��
O � /'�/ / � � Page number \
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Assessed value of reat property a of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitabie
March 1, current year March 1, curcenl year owneR ❑ Yes ❑ No
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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 lhan that of applicant, indicate below: Is the property in question:
❑ Real Property � Mobile Home (IC 61.1-�
3me of moAgagee or conVact seller
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Address of mortgagee or conVad seller (number and street, city, state, ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in fhe amount of:
zoo zo 0 20 �l� zo �°� zo 0 9 zo �_ zo
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Signature County Auditor Date
�/ We certiTy under the penalty of peryury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
ignature (own s lull name) Person authorized by duty executed Power oi Attomey
\ ar by IC 6-1.1-12-.07
Full re ' nt addr af appli nt Address of authorized person
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