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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03)
Presaibed by Department of Local Govemment Finance
INSTRUCTIONS:
To be /iled in person or 6y mail with the CountyAuditor of the county where tha property is located.
Filing Dates: 9) Real Property: Dunng the 12 months belore May 11 0/ fhe year the deduction rs to be eBective. QF� R%( 20�4
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tAe year th/e deduction is to ///be��� effective.
See reverse side for additional instructions and qualiTcations. �/l , / J� n�
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Applicant(ownerorcontrac(buyer-s strictionso reverseside)
Taxing District Key number / legal desuiption Record number
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�/�_ O D b� 7—� Page number �
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
MarcF� 1, current year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exad share ot interest? f owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
O Real Property ❑ Mobile Hortie (IC 61.1-�
�'ame of mortgagee or contraIX seller �
Address of mortgagee or contrad selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrrent yea(?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 ��P 20 � 20 ,-0,� 20 6/ 20 20
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Signature County Auditor � Date
�'/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
� resident of Indiana and owner of the aforementioned property on March t, 20
Signature (ow ers hdl name) Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
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