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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R6 / 5-06)
PreSrribed by Depertment of Local Gwemment Finance
Coun Township Year
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To beRfilued�lnOperson or by mail with the County Auditor o/ the county where the property is located. MAR ���1 ZO��
Filing Dates: 1) Real Property: During the 72 months 6efore June Il o/ fhe year the deduction is to be effective.
2) Mobile Homes assessed unde� IC 6-1.1-7: Belween January 15 and March 2 of the year fhe;�duc��o be effective.
See reverse side for additional instrucGons and qualrfcaUons. GIBSON C NiY AUDITOR
Applicant (owne� or contract buyer - s resfrictions on reverse side)
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Taxin � istrict � Key number / legal description Record number O�
��,� a�-r9-3o-yvd_ooa �c�� pagenumber �/��
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? � Yes � No
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If no, what is his / her exad share of interest? If owned with someone oiher than spouse, indicate with whom.
If name on record is dif(erent than that of applicant, indicate below: Is the property in question:
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�e of mortgagee or contra t seller ��S � \���r A /� �. I
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Address of moRgagee or contract selier (number and street, city, state, ZIP
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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 DistricY? Has this deduction been requested on
county in Indiana? property for current year? ❑ YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20�� 20 2o OQ 20 20 20 20
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Signature County Auditor Date
I I We certify under the penalty of peryury that the above and foregoing iniortnation is Vue and correct and that the applicants was / were
sident oi Indiana and owner of the aforementioned property on March 1, 20
S� nature (owner's full name) _ Person authorized by duly executed Power of Attomey
� (l `� or by IC 6-1.1-12-.07
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F II resident address of applicant Address of authorized person
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