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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�` ! State Fortn 43709 (R5 / 4-03) � . . �
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Prescnbed Dy Department of �oral Govemment Finance
To beRU �TION rson or by mail with the County Auditor of the county where the property is located. ��� a� �
Filing Dates: 7) Real Property: Dunng the 12 months before May 11 01 the year the deduction is to be eHective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the d i � t Hective.
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See reverse side for additional instructions and qualifications.
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Applicant (owne r on ct buyer see 2st ' tio on e GI ON COUNTY AUDITOR
T DistriIX Key number / legal descri ion Record number �
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Assessed value of reaf property as of MoAgage / Contrad indebtedness unpaid as of Is lhe applicant th sole legal or equitable
March 1, curcent year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of inleresl? If owned with someone other than spouse, indicate with whom.
If name on record is different fhan that of applicant, indicate below: Is the property in question:
� Reai Property ❑ Mo6i Home QC 61.1-�
me of mortgagee or conlract seiler
Address ot mortgagee or contrad seller (number and street, ty, state, ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �. 20 _Q� 20 �� 20 20 20 20
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Signature County Auditor Date
�We certity under the penalty of perjury lhat lhe above and foregoing information is true and correct and that ihe applicants was / were
� resident of Indiana and owner of the aforementioned propeAy on March t, 20
Signature (owners lull name Person authorized by duty executed Power of Atlorney
� or by IC 6-1.1-12-.07
Full iden ddress of applicant Address of authorized person
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