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STATEAAENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
� ! Sute Fwm 43709 (RS / a-03)
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PrescdDed by Depanment ot Lora� Govemment Finance
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INSTRUCTIONS:
Coun Township Year
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OC I F��e:n�aAi14
To be filed in person or by mail with the County Auditor of the counry where the property is located. ` n
Filing Dafes: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be e/%ctive. �� n �
2) Mo6ile Homes assessed under IC 6-7.1-7: Between January 75 and March 2 of the year the.deduction'is`to be /effective.
See reverse side for additional insfnictions and qualifications.
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Applicant (ownerorcontract buyer- see restnctions on reverse side)
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Tazing Disirid Key number / legal scription cord number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant th ole legal or equitable
March 1, wrrent year March 1, current year ownef? �s ❑ No
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If no, what is his / her exact share ot interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is the property in question:
eal Property ❑ Mobile Home pC 61.1-�
"-�ne of mortgagee or contrad seller
Address of mortga e or contract seller (number and street, 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 Distrid? Has this dedudion been requested on
county in Indiana? property for current year? 0 Yes� No
COUNTY AUDITOR
Deduction approved in fhe amount of:
20 20 20�� 20 09 20 20 20
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Signature County Auditor Dale
'� We certify under the penalty of perjury thal the above and foregoing information is true and corred and lhal ihe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
3ignature (owners /ull ame) Person authorized by duly executed Power of Attomey
- or by IC 6-1.1-12-.07
Full esident dress o applica Address of authorized person
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