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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION n Township Year
�' «• ! State Fwm 43709 (RS I a-03) _.
� PrescnDed by Departrtrent of Loral Govemment Finance , �
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INSTRUCTIONS: File ark
To be filed in person or by mail with the County Auditor of the county where the property is locat /
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is . $ •
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of e('}1�/��I �' Nective.
See reverse side for additional inshuctions and qualifications.
Applicant (o r contract b er- see res 'cti s o verse side)
� y
Tauing i rid K mber / g I description Record number
��n /� , qy� / � � Page number � �
CG d�/�C/ ILCJ (Q
Assessed value of real property as Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cument year March 1, current year owne(? ❑ Yes ❑ No
�c.i `-i
Ii no, what is his / her exact share o( inlerest? If owned with someone olher than spouse, indicate with whom.
If name on record is different lhan ihat of applicant, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�e of mortgagee or contrad seller •
Address of moAgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, state, ZIP code)
Does applicant own propeAy in any other If yes, what county? What Taxing District? Has this deduction been requested on
counry in Indiana? propeAy for curtent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
20 OG 20 67 20 Di 20 6 20 20 20
� �
Signature County Auditor Dale
�' We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signat e owners lull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident addre f applican Address of authorized person