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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Form 43709 (R4 / 10-01)
Presaibed by DeOanmenl W Loal Govemment Finance
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� .1uN 4 2003
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Audrfor of the county where the property is focated. /�
Filing Dates: 1) Real Prope�ty: During the 12 months be(oie May 11 0/ the year the deduction is to be,c.l�� ffective. .
2) Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 31 of the ye*a[:(be �ledu�'on is to�be�eHective.
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See reverse side for additional instruc6ons and qualifica6ons.
Applican ( mer or tract buy - se reshictions on re�e side) �J J �)
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Tauing Distr Key number / legal description Record number —� S7 �
--7 Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrtent year 'March 1, cunent year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interesl? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than that of applicani, indicate below: Is lhe �operty in question:
CSReaI Property ❑ Mobile Horne pC E1.1-�
�me of mortgagee or conVad seller `
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A'ddress of mortgagee or conVad seller (number and st2et, city, state, ZIP
Name of assignee or ofher owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Dces applicant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
county in Indiana? property for curtent yeaR 0 Yes � No
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Deduction approved in fhe amount of:
20 � 20 �_ 20 Q!� 20 20 �� 20 0 20
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Sgnature County Audftor Date
/ We certify under lhe penalty af perjury lhai the above and foregoing infortnation is lrue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March t, 20
ig ature (owner's full name Person authorized by duly execuled Power of Attomey
- or by IC 6-1.1-12-.07
ull re ent address ot applipnt � ,o Address of authorized person
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