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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
� �FOR DEDUCTION FROM ASSESSED VALUATION
Sta;e Fwrt: 43709 (RS / a-03)
P:escnDeA Cy Department ot Loc�al Govemment Finance
INSTRUCTIONS: �
Cou Tow Year
� U 2005
File Mark
To be filed in person or 6y mail with the County Auditor o( the county where the property is located. p�(„� �
Filing Oates: 1) Real Property: During the 12 months 6efore May 11 of tbe year the deduction is ro be�(� �g
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oI the year tfie�Je��RI�T }'s,tq�g��ctive.
See reverse side for additional instructioris and quali(cations.
Applicant (owner or contract b er - see resMc ' ns o�verse side)
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Taxing Distnd - � Key number / legal description Rewr umber ��.,
����y� �O n,� jl�l �� %� Page number �` O
� � t.Vor ���- b
Assessed value ot real property as of Mortgage / ContreU indebfedness unpaid as of Is the applicant ihe sole legal or equitable
March 1, current year March 1, wrrent year ownef? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? if owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate betow: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
'�me of mortgagee or conlraIX seller
Address of mortgagee or contract seller (number and street, city, state, IP
Name of assignee or other owner or holder of mortgage
Address of assignee�(numbe�andst2et, city, state, ZlPcode)
Does applicant rnvn property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? � property for wrrent year? � Yes � No
COUNTY AUDITOR
Dedudion approved in fhe amount ot:
20 20 20 D`I 20 20 20 20
P -P P
Signature County Auditor Date
�! We� �rtify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
a r ident oflndiana and owner of the aforementioned property on March 1, 20
nature (owners full name) `� Person authorized by duly executed Power of Atlorney
or by IC 6-1.1-12-.07
F si a dr ss pplicant. Address of authorized person
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