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��� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R6 / 5-06)
�� Presaibed by Department af Lo�l Gwemment Finaixe
INSTRUCTIONS:
Count Township Year
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FEB 1 ����a�
To be filed in pe�son o� by mail with fhe CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 monfhs before ,lune I f ol the year the deduction is to be e/i ,Q
2) Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 0( the ygSON C NTYn���eflective.
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See �everse side for additional instiuc6ons and qual"fiications.
Applicant wner or contract buy s �e restnctions on reverse side)
Taxing Distrid Key number / legal description Record number D�
— ' �� ' �v' /1 / ��� �� Page number Q �
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Assessed vatue of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant ihe sole legal or equitable
March 1, curtent year March 1, current year . owne�? ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
e of mortgagee or contrad seller
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Address of mortgagee or contract seller (n ber and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state, ZIP code) �
Dr:i�vcr \o. ��-.. �?° �— ;
......
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Does applicant own property in any other If yes, what county? WF i � requested on
countyinlndiana? C��-� \'�, ... I?�YesONo
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COUNTY AUDITOR
Deduction approved in the amounf of:
20 �$_ 20 � 20 20 20 20 20
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Signature County Auditor Date
e certify under ihe penaity of perjury lhat the above and foregoing infortnation is true and corred and that ihe applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
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Signature (owne/s (ull name) Person authorized by duly executed Power of Attomey
O' or by IC 6-1.1-12-.07
Full resident address of appli t Address of authorized person
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