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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
's J Siate Fwm 43709 (RS I 4-03)
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� PfescnDeC Dy Department ot laal GovemmeM Finance
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�NSrRUCnon,s: �AN � 3 200�Site Mark
To be �led in person or 6y mail with the County Auditor ot the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is�� (/Bective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( tµ��ction is to be eNective.
See reverse side for additional instructions and qualifications. Q�BSON COU�y qU
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Applicant (ovmerorcontract buy r- see restnctions on reverse side)
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Taxing District Key number / legal description Record numberO L1 ^ A� 1 �
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Page number
d �- o0 1- ct) �`fi ra � ti-
Assessed value of real property as of Mortgage / Contrad indebledness unpaid as of Is the applicant �th,,�e ole legal or equitable
March 1, cunent year March 1, current year owner? LYYes ❑ No
1 � a UO
If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than ihat of applicanl, indicate below: Is the property in question:
❑�eal PropeAy O Mobile Home (IC Cr1.1-�
�e of mortgagee or contract seller �/�
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Address of morigagee or contrad seller (number and st�et, city, state, ZIP
Name of assignee or other owner or holder oi mortgage '
Address of assignee (num6er and st2et; city, state, ZIP code) .
Does applicanl own property in any other If yes; what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year?� YesO No
COUNTY AUDITOR
Deduction approved in lhe amounf of:
20 �Q(� 20 O 20 _� 20 � 20 20 20
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Signature County Auditor Date
�' We certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Si ure (owners full name) Person authorized by duly executed Power of Attomey
� /J or by IC 6-1.1-12-.07
ull re den[ address of applicant Address of authorized person
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