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�e� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'+'�'; FOR DEDUCTION FROM ASSESSED VALUATION
b� __ . y' SUte Form 43709 (R6 / 5-06) �
�« Presaihed by Deparimenl of Lorai Govemment Finance
�
INSTRUCTIONS: '°
To 6e filed in person or by mail with the County Auditor of the county where the property is lo�
Filing Dates: 1) Real Property: Dunng the 12 months befo2 ,lune 17 0/ the year the deduction
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2
See reverse side (or additional instructions and quali�cations. �
Applicant (puy�ie� or contract buyyr - see
Taxing Dislrid a
�.��� Q��
Assessed vatue oi real property as of
March 1, current year
If no, what is his / her exact share of inter°si?
If name on record is different than that of
of moAgagee or contrad
on revehse side)
is to be eflective.
Key number / legal escriplion Record number
�/9/6 � �i��9 � � � :
Page number � � � c�
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MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
�� �/1�� /Oe�.n�D
below:
If owned with someone other than spouse, indicate wilh whom. •
Address of moAgagee or contrad seller (number and street, city, sfate, ZIP
Name of assignee or other awner or holder of mortgage
Address of assignee (num6erand sfreet, ciry, state, ZIP
Does applicanl own propeRy in any other If yes, what county? What Taxing Distrid?
county in Indiana?
Deduction appro� ed in the amount of:
20 0 �_
1
Signature
COUNTY AUDITOR
20 �_ 20 �'� I 20 20
�
County Auditor
s the property in question:
❑ Real Property ❑ Mobile Hmie (IC 61.1-�
Has this deduction been requested on
property for current yeaR � Yes ❑ No
20
Date
20
�/ We certiry under lhe penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was /"vrere
resident of Indiana and owner of the aforementioned property on March 1, 20
Signat re (owners (ull name) Person authorized by duly executed Power of Attomey
� `t� �g,1,�� �, ��� or by IC 6-1.1-12-.07
Fuli resident address of �pplicant Address of authorized person
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