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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S J State Form 43709 (R5 / 4-03)
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PrescnDed by Department of Local Govemment Finance � '
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INSTRUCTIONS: APR 7 200�rile Mark
To be filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Properry Dunng the 12 months be(ore May 11 0/ the year the deduci�is to be efrecti�: n n
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marchk o tbe � tkhe�ed�uction ��o be eHective.
See reverse side for additional instructions and qualifrcations. �� Gi°SON �'n�'^ i � A �"'Tr' �
Applicant (ow or contract buyer - ee restrictions on reverse side)
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Taxing Distri number! legal description Record number D?
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l� /� / GQ /��I� Page number a � � � � ��
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Assessed value ot real prope as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is different ihan ihat of applicant, indicate below: Is the property in question:
❑ Real Propsty ❑ Mobile Hmie (IC 61.1-�
Name of moRgagee or contrect seller L�
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Address of mortgagee or contract seiler (number and st2et, ci , state, ZIP � I
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Name of assignee or other owner or holder of mortgage �
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? �een requested on
county in Indiana? � year? � Yes ❑ No
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Drawer NO.� �,.5„��,�
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Deduction approved in the amount of: Card N� . .....................
20 � 20 0(0 20 �'� 20 �L 20 �_ 20 20
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Signature Counfy Auditor Date
I/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
�a r ident of Indiana and owner o the aforementioned property on March 1, 20
i ature owners full name Person authorized by duty executed Power of Attomey
' or by IC 6-7.1-12-.07
ull resi ent addre o a ' nt Address of authorized person
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