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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
� �w� ! State Fwm 43709 (RS I 4-03) . � _
Prescribetl by Department ot Local Govemment Finance
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INSTRUC710NS: . File Mark
To 6e filed in person or by mail with the County Auditor of the county where the property is located. �
Filing Dafes: 1) Real PropeRy: During the 12 months before May 11 0/ the year the deduction is to be effeet�ve�"' '6
2) Mobile Homes assessed under IC 6-L 1-7: Between January 15 and March 2 of the }�e��(�c(,e�uqp@q �s �Ctre3�f(ective.
See reverse side Ior additional instructions and qualifications.
Taxing �
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nber / legaf description Record number O
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Assessed value of real property as of Mortga e/ Contrect indebfedness unpaid as of Is the applicant the sole egal or equitable
March 1, current year March 1, current year ownef? � Yes ❑ No
��a� o o d �
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 lhan that of applicanl, indicate below: Is the property in question:
_ ❑ Real Property ❑ Mobile Home (IC 61.1-�
mortgagee or contract seller
Address of mortgagee or conlrad seller (number and
Name of assignee or other owner or holder of mortgage
city,
i
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other I( yes, what counry? I What Taxing Distrid?
county in Indiana? �
20 � �i
P
Signature
COUNTY AUDITOR
approved in the amounl of:
_ 20 � 20 � 20 20
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Counry Auditor
Has this dedudion been requested on
property for current year? � Yes ❑ No
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
�ent of Indiana and owner of the aforementioned property on March 1, 20
� e(owne 11 nam Person authorized by duly exewted Power of Attomey
�� or by IC 6-1.1-12-.07
Full resident address of applicant �Address of authorized person