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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
,FOR DEDUCTION FROM f}SSESSED VALUATION Coun Township Year
S« / State Fwm 43709 (RS / 4-03)
Piascnb�W by Depanment of �ocal Govemment Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 months before May 11 oI the year the deduction is to 6e ellective— r
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduc[ion is to be'e ecff ti�
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See reverse side for additional instructions and qual�catrons. �- _!: .[�,d �j ';
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Applicant (ownerorcontracf buyer- s restrictions on revers�side) �„ '
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Taxi ist Key number / legal descriplion Record numtier�.���� �` �� �j q�iD�TOR
�Q Q►^ � O� X�Z � Page number
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Assessed value of real property as of Mortgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, curtent year March 1, w t y ar owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than Ihat of applicant, indicate below: Is lhe property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�ame of mortgagee or contrad seller
Address of mortgagee or contract seller (number and street, , state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 Q� 20 Q f� 20 �� 20 _Q� 20 0 20 20
'T� �' P � P
Signature County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that ihe applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
e(owners /ull nam Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
r sideAt� res a lic� t� G s Address of authorized person
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