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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION un Township Year
S M� J, Siate Form 43709 (RS / 4-03) ��
� � PresrnGeE Dy Departmenl o( Local Govemmenl Finance
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INSTRUCTIONS: � File Mark
To be filed in person or by mail with the County Auditor o) the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 mon(hs before May 11 0/ the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side for additional rnstructions and quali(cations.
Applicant (owner o tracf buyer - see restrictions o reverse ' e�cl )_
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Taxing Distrid Key number / legal description Record number �� �
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V'! � c�J 10
Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant th ole legal or equitable
March 1, current year March 1, current year ownef? �s ❑ No
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If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
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If name on record.is different than thaf of applicant, indicate below: a' Is e property in question:
. - �al Property ❑ Mobile Home QC 61.7-�
�me of moRgagee or contract seiler
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Address of mortgagee or contrad seller (number and sfreet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address oF assignee (number and street, city, state, ZIP code) �
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduc� been requested on
coun�y in Indiana? p�eAy for cu nl year?� Yes❑ No
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COUNTY AUDITOR a �
Deduction approved in the amount of: ^ i
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zo 0 6 zo � 20 �$_ zo 2o zo zo
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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 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07
Full resident address of applicant Address of authorizzd person