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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03)
PiesaiEeE by Department ot Laral Govemment Finance
Coun Township Year
INSTRUCTIONS: � �File-Maric
To 6e filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 0) the year the deducfion is to be e hve. � '
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 of the year the dg�fuCcT l's to be e e i e.
See reverse side for additronal inshuctions and qual�cations. U -. 1 2�(j.i
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Applica wn r o� contract buyer - see resMchqns re e si ) n /��-
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Taxing Districf K y number / legal description Record number %�
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L���ivvY1-(� oO7—i'��7 0b –�O Pagenumber QOIS
Assessed value of real property as of Mortgage / Contracl indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, cur ent year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of inierest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 6-1.1-7)
��e of mortgagee or wntracl seller ��
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stre -- -- -
DrawerNO ................... Dr;
Does applicant own property in any otY I . Has this deduction been requesied on
counry in Indiana? Card NO. �� � /� a�� Ca property for current year? � Yes❑ No
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Deduction approved in the amount of:
20 20 � 20 20 20 � 20 � 20
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Signature Counry Auditor Date
�We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
Signatur Kown r's (ull name) Person authorized by duly executed Power of Attomey
_, or by IC E1.1-12-.07
Full resident address of applicant Address of authorized person
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